VATI GREENLIGHT MATERNITY & NEWBORN NURSING
EXAM (RN) COMPLETE QUESTIONS WITH VERIFIED
ANSWERS AND RATIONALES
1. A nurse is caring for a client who is at 38 weeks of gestation and reports a
sudden gush of fluid from the vagina. Which of the following actions should the
nurse take first?
Assess the fetal heart rate
Check the fluid for meconium
Test the fluid with nitrazine paper
Ask the client to ambulate to promote labor
Correct Answer: Assess the fetal heart rate
Rationale: After rupture of membranes, the priority is to assess the fetal heart
rate to detect umbilical cord compression or prolapse, which can be life-
threatening to the fetus.
2. A nurse is reinforcing teaching with a client who is at 12 weeks of gestation
about an alpha-fetoprotein (AFP) screening. Which of the following statements
by the client indicates understanding of the teaching?
This test screens for neural tube defects and Down syndrome
This test will tell me for certain if my baby has a birth defect
This test is performed at 28 weeks of gestation
This test requires a sample of amniotic fluid
Correct Answer: This test screens for neural tube defects and Down syndrome
,Rationale: Maternal serum AFP screening at 15 to 20 weeks screens for neural
tube defects (spina bifida, anencephaly) and chromosomal abnormalities like
Down syndrome.
3. A nurse is assisting with the admission of a client who is in active labor and
has a history of herpes simplex virus. Which of the following questions is most
important for the nurse to ask?
Do you currently have any visible lesions on your genitals?
How long ago were you diagnosed with herpes simplex virus?
Have you taken acyclovir during this pregnancy?
Does your partner have a history of herpes simplex virus?
Correct Answer: Do you currently have any visible lesions on your genitals?
Rationale: Active genital herpes lesions at the time of delivery are an indication
for cesarean section to prevent neonatal herpes infection. This is the priority
assessment.
4. A nurse is reinforcing teaching with a client who is at 8 weeks of gestation and
experiencing nausea and vomiting. Which of the following instructions should
the nurse include?
Eat dry crackers before getting out of bed in the morning
Drink a large glass of water with each meal
Lie down immediately after eating each meal
Avoid eating any carbohydrates during the first trimester
Correct Answer: Eat dry crackers before getting out of bed in the morning
Rationale: Eating dry crackers or toast before rising helps prevent morning
sickness by stabilizing blood glucose and reducing gastric empty stomach
irritation.
,5. A nurse is collecting data from a client who is at 36 weeks of gestation and has
preeclampsia. Which of the following findings should the nurse report to the
provider immediately?
Epigastric pain and a headache that does not resolve with rest
Blood pressure of 140/90 mm Hg
1+ proteinuria on urine dipstick
Pedal edema that is present in the morning
Correct Answer: Epigastric pain and a headache that does not resolve with rest
Rationale: Epigastric or right upper quadrant pain and persistent headache are
signs of severe preeclampsia and possible HELLP syndrome, indicating worsening
disease requiring immediate intervention.
6. A nurse is caring for a client who is receiving oxytocin for augmentation of
labor. The nurse notes that the client's contractions are occurring every 90
seconds and lasting 90 seconds. Which of the following actions should the nurse
take first?
Stop the oxytocin infusion
Decrease the oxytocin infusion rate
Reposition the client on her left side
Increase the maintenance IV fluid rate
Correct Answer: Stop the oxytocin infusion
Rationale: Contractions occurring more frequently than every 2 minutes and
lasting longer than 90 seconds indicate uterine tachysystole. The oxytocin infusion
should be stopped immediately to prevent uterine rupture or fetal distress.
7. A nurse is reinforcing teaching with a client who is at 28 weeks of gestation
about the signs of preterm labor. Which of the following statements by the
client indicates understanding of the teaching?
, I will report any low, dull backache that comes and goes
I will report any increase in fetal movement
I will report any weight gain of more than 1 pound per week
I will report any difficulty sleeping at night
Correct Answer: I will report any low, dull backache that comes and goes
Rationale: Low, dull backache that comes and goes is a common sign of preterm
labor. Other signs include uterine contractions, pelvic pressure, menstrual-like
cramping, and vaginal discharge changes.
8. A nurse is assisting with the admission of a client who is at 40 weeks of
gestation and reports contractions every 3 to 4 minutes. A vaginal examination
reveals the cervix is 5 cm dilated and 90% effaced. Which of the following
phases of labor is the client in?
Active phase
Latent phase
Transition phase
Second stage of labor
Correct Answer: Active phase
Rationale: The active phase of the first stage of labor is characterized by cervical
dilation from 4 to 7 cm. The latent phase is 0 to 3 cm, and transition is 8 to 10 cm.
9. A nurse is caring for a client who is 2 hours postpartum following a vaginal
delivery. The nurse notes that the client's fundus is boggy and deviated to the
right of the midline. Which of the following actions should the nurse take first?
Assist the client to void and then reassess the fundus
Administer methylergonovine as prescribed
Notify the provider of the fundal findings
Massage the fundus vigorously
EXAM (RN) COMPLETE QUESTIONS WITH VERIFIED
ANSWERS AND RATIONALES
1. A nurse is caring for a client who is at 38 weeks of gestation and reports a
sudden gush of fluid from the vagina. Which of the following actions should the
nurse take first?
Assess the fetal heart rate
Check the fluid for meconium
Test the fluid with nitrazine paper
Ask the client to ambulate to promote labor
Correct Answer: Assess the fetal heart rate
Rationale: After rupture of membranes, the priority is to assess the fetal heart
rate to detect umbilical cord compression or prolapse, which can be life-
threatening to the fetus.
2. A nurse is reinforcing teaching with a client who is at 12 weeks of gestation
about an alpha-fetoprotein (AFP) screening. Which of the following statements
by the client indicates understanding of the teaching?
This test screens for neural tube defects and Down syndrome
This test will tell me for certain if my baby has a birth defect
This test is performed at 28 weeks of gestation
This test requires a sample of amniotic fluid
Correct Answer: This test screens for neural tube defects and Down syndrome
,Rationale: Maternal serum AFP screening at 15 to 20 weeks screens for neural
tube defects (spina bifida, anencephaly) and chromosomal abnormalities like
Down syndrome.
3. A nurse is assisting with the admission of a client who is in active labor and
has a history of herpes simplex virus. Which of the following questions is most
important for the nurse to ask?
Do you currently have any visible lesions on your genitals?
How long ago were you diagnosed with herpes simplex virus?
Have you taken acyclovir during this pregnancy?
Does your partner have a history of herpes simplex virus?
Correct Answer: Do you currently have any visible lesions on your genitals?
Rationale: Active genital herpes lesions at the time of delivery are an indication
for cesarean section to prevent neonatal herpes infection. This is the priority
assessment.
4. A nurse is reinforcing teaching with a client who is at 8 weeks of gestation and
experiencing nausea and vomiting. Which of the following instructions should
the nurse include?
Eat dry crackers before getting out of bed in the morning
Drink a large glass of water with each meal
Lie down immediately after eating each meal
Avoid eating any carbohydrates during the first trimester
Correct Answer: Eat dry crackers before getting out of bed in the morning
Rationale: Eating dry crackers or toast before rising helps prevent morning
sickness by stabilizing blood glucose and reducing gastric empty stomach
irritation.
,5. A nurse is collecting data from a client who is at 36 weeks of gestation and has
preeclampsia. Which of the following findings should the nurse report to the
provider immediately?
Epigastric pain and a headache that does not resolve with rest
Blood pressure of 140/90 mm Hg
1+ proteinuria on urine dipstick
Pedal edema that is present in the morning
Correct Answer: Epigastric pain and a headache that does not resolve with rest
Rationale: Epigastric or right upper quadrant pain and persistent headache are
signs of severe preeclampsia and possible HELLP syndrome, indicating worsening
disease requiring immediate intervention.
6. A nurse is caring for a client who is receiving oxytocin for augmentation of
labor. The nurse notes that the client's contractions are occurring every 90
seconds and lasting 90 seconds. Which of the following actions should the nurse
take first?
Stop the oxytocin infusion
Decrease the oxytocin infusion rate
Reposition the client on her left side
Increase the maintenance IV fluid rate
Correct Answer: Stop the oxytocin infusion
Rationale: Contractions occurring more frequently than every 2 minutes and
lasting longer than 90 seconds indicate uterine tachysystole. The oxytocin infusion
should be stopped immediately to prevent uterine rupture or fetal distress.
7. A nurse is reinforcing teaching with a client who is at 28 weeks of gestation
about the signs of preterm labor. Which of the following statements by the
client indicates understanding of the teaching?
, I will report any low, dull backache that comes and goes
I will report any increase in fetal movement
I will report any weight gain of more than 1 pound per week
I will report any difficulty sleeping at night
Correct Answer: I will report any low, dull backache that comes and goes
Rationale: Low, dull backache that comes and goes is a common sign of preterm
labor. Other signs include uterine contractions, pelvic pressure, menstrual-like
cramping, and vaginal discharge changes.
8. A nurse is assisting with the admission of a client who is at 40 weeks of
gestation and reports contractions every 3 to 4 minutes. A vaginal examination
reveals the cervix is 5 cm dilated and 90% effaced. Which of the following
phases of labor is the client in?
Active phase
Latent phase
Transition phase
Second stage of labor
Correct Answer: Active phase
Rationale: The active phase of the first stage of labor is characterized by cervical
dilation from 4 to 7 cm. The latent phase is 0 to 3 cm, and transition is 8 to 10 cm.
9. A nurse is caring for a client who is 2 hours postpartum following a vaginal
delivery. The nurse notes that the client's fundus is boggy and deviated to the
right of the midline. Which of the following actions should the nurse take first?
Assist the client to void and then reassess the fundus
Administer methylergonovine as prescribed
Notify the provider of the fundal findings
Massage the fundus vigorously
