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Question 1
A pregnant client at 10 weeks’ gestation reports nausea and vomiting. Which
recommendation should the nurse provide?
A. Drink fluids only with meals
B. Eat a large meal in the morning
C. Eat small, frequent meals throughout the day
D. Avoid all carbohydrates
Answer: C
Rationale: Small, frequent meals help stabilize blood glucose levels and reduce gastric
irritation, which can significantly decrease nausea during the first trimester. Large meals
and fluid intake with meals can worsen nausea, while eliminating carbohydrates is
unnecessary and may reduce energy availability.
Question 2
A client in labor reports contractions every 3 minutes lasting 60 seconds. What is the
priority nursing action?
A. Encourage the client to ambulate
B. Assess fetal heart rate
C. Perform a vaginal examination
D. Prepare for immediate delivery
Answer: B
,Rationale: Assessing fetal heart rate ensures fetal well-being during active labor. Fetal
monitoring is the priority before other interventions. Ambulation or vaginal exams may
follow but are not first-line actions in this scenario.
Question 3
Which finding in a newborn requires immediate intervention?
A. Acrocyanosis
B. Heart rate of 150 bpm
C. Respiratory rate of 20 breaths per minute
D. Presence of vernix on the skin
Answer: C
Rationale: A respiratory rate of 20 breaths per minute is below the normal newborn
range (30–60 bpm) and may indicate respiratory distress or depression requiring
immediate evaluation.
Question 4
A postpartum client has a firm uterus but heavy vaginal bleeding. What is the most likely
cause?
A. Uterine atony
B. Laceration of the birth canal
C. Retained placental fragments
D. Infection
Answer: B
Rationale: A firm uterus with continued heavy bleeding suggests trauma such as
lacerations rather than uterine atony. Lacerations require surgical or procedural repair.
Question 5
Which instruction should the nurse include in discharge teaching for a client after a
cesarean birth?
, A. Avoid all physical activity for 6 weeks
B. Monitor incision for redness and drainage
C. Keep incision uncovered at all times
D. Avoid breastfeeding while on pain medication
Answer: B
Rationale: Monitoring for infection signs such as redness, swelling, or drainage is
essential. Complete inactivity is not recommended, and breastfeeding is generally safe
with prescribed analgesics.
Question 6
A pregnant client is diagnosed with gestational diabetes. Which meal choice is most
appropriate?
A. White bread and orange juice
B. Grilled chicken with brown rice and vegetables
C. Pancakes with syrup
D. Candy bar and soda
Answer: B
Rationale: Balanced meals with protein, complex carbohydrates, and fiber help maintain
stable blood glucose levels. Simple sugars should be avoided.
Question 7
What is the priority assessment immediately after delivery of the newborn?
A. Reflexes
B. Weight
C. Apgar score
D. Length
Answer: C
Rationale: The Apgar score evaluates newborn adaptation at 1 and 5 minutes after birth
and determines immediate need for intervention.