NURS230 Maternal-Newborn Nursing Exam Prep – Real Practice
Questions, Answers & Detailed Rationales (Updated 2026) | Prenatal &
Postpartum Care, Labor & Delivery Nursing, Fetal Monitoring & Obstetric
Assessment, Newborn Care & Neonatal Disorders, High-Risk Pregnancy
Complications, Maternal Pharmacology, Family-Centered Care, Patient
Education & NCLEX-Style Clinical Judgment Review
Question 1: A nurse is assessing a pregnant client at 32 weeks gestation. Which
finding should the nurse report to the healthcare provider immediately?
A. Mild ankle edema that resolves with elevation
B. Blood pressure of 148/96 mm Hg on two readings 4 hours apart
C. Weight gain of 1 pound per week
D. Complaints of occasional heartburn after meals
CORRECT ANSWER: B. Blood pressure of 148/96 mm Hg on two readings 4 hours
apart
Rationale:A blood pressure of 148/96 mm Hg on two separate readings meets the
diagnostic criteria for gestational hypertension or preeclampsia, which requires
immediate evaluation to prevent progression to severe complications such as
eclampsia, HELLP syndrome, or placental abruption. Mild edema, appropriate weight
gain, and heartburn are common, expected findings in the third trimester.
Question 2: During the immediate postpartum period, a nurse notes that a client's
fundus is boggy and displaced to the right. What is the priority nursing action?
A. Administer prescribed oxytocin intravenously
B. Assist the client to empty her bladder
C. Massage the fundus vigorously until firm
D. Document the finding and continue monitoring
CORRECT ANSWER: B. Assist the client to empty her bladder
Rationale:A boggy, displaced fundus is often caused by a distended bladder, which
prevents adequate uterine contraction and increases the risk of postpartum
hemorrhage. Assisting the client to void is the priority intervention; fundal massage
should follow only after bladder emptying if the uterus remains boggy. Administering
oxytocin may be indicated later but is not the first action.
Question 3: A newborn is assessed at 1 minute of life with the following: heart rate
90 bpm, slow irregular respirations, some flexion of extremities, grimace to
stimulation, and body pink with blue extremities. What is the newborn's Apgar
score?
A. 4
B. 5
C. 6
D. 7
,CORRECT ANSWER: B. 5
Rationale:The Apgar score assigns 1 point for heart rate <100 bpm (90 bpm), 1 point for
slow/irregular respirations, 1 point for some flexion (muscle tone), 1 point for grimace
(reflex irritability), and 1 point for acrocyanosis (body pink, extremities blue). Total = 5.
This score indicates moderate difficulty requiring supportive care such as stimulation
and oxygen.
Question 4: Which statement by a pregnant client at 10 weeks gestation indicates a
need for further teaching about nutrition?
A. "I will increase my intake of leafy green vegetables for folate."
B. "I should avoid all caffeine during my pregnancy."
C. "I need about 300 additional calories per day during the second trimester."
D. "I will take my prenatal vitamin with a glass of orange juice."
CORRECT ANSWER: B. "I should avoid all caffeine during my pregnancy."
Rationale:Current guidelines suggest limiting caffeine to less than 200 mg per day
(about one 12-oz cup of coffee), not complete avoidance. The other statements reflect
accurate knowledge: folate prevents neural tube defects, caloric needs increase in the
second trimester, and vitamin C enhances iron absorption from prenatal vitamins.
Question 5: A nurse is preparing to administer Rho(D) immune globulin to a
postpartum client. Which assessment finding is essential before administration?
A. Mother's blood type is Rh-negative
B. Newborn's direct Coombs test is negative
C. Mother has no history of Rh sensitization
D. Newborn's blood type is Rh-positive
CORRECT ANSWER: D. Newborn's blood type is Rh-positive
Rationale:Rho(D) immune globulin is indicated only when an Rh-negative mother
delivers an Rh-positive infant, to prevent maternal sensitization to Rh-positive blood
cells. While the mother's Rh-negative status and lack of prior sensitization are
prerequisites, the newborn's Rh-positive status is the critical determinant for
administration.
Question 6: A client in active labor reports sudden, severe abdominal pain and a
sensation of "tearing." The nurse notes fetal bradycardia and maternal tachycardia.
Which complication should the nurse suspect?
A. Placenta previa
B. Uterine rupture
C. Amniotic fluid embolism
D. Cord prolapse
CORRECT ANSWER: B. Uterine rupture
,Rationale:Sudden tearing pain, fetal bradycardia, and maternal tachycardia are classic
signs of uterine rupture, a life-threatening obstetric emergency often associated with
prior cesarean delivery or uterine surgery. Immediate intervention includes preparing for
emergency cesarean birth. Placenta previa presents with painless bleeding; amniotic
fluid embolism causes acute respiratory distress; cord prolapse shows variable
decelerations.
Question 7: Which finding in a 24-hour-old newborn requires immediate nursing
intervention?
A. Respiratory rate of 55 breaths per minute
B. Temperature of 97.8°F (36.6°C) axillary
C. Passage of meconium stool
D. Central cyanosis during crying
CORRECT ANSWER: D. Central cyanosis during crying
Rationale:Central cyanosis (bluish discoloration of the lips, tongue, or trunk) indicates
hypoxemia and possible congenital heart disease or respiratory pathology, requiring
urgent assessment and intervention. A respiratory rate of 55 is within the normal
newborn range (30-60/min); mild hypothermia can be corrected with warming;
meconium passage is expected within 24-48 hours.
Question 8: A nurse is teaching a postpartum client about signs of infection. Which
symptom should the client report immediately?
A. Mild perineal discomfort with sitting
B. Lochia rubra lasting 4 days
C. Temperature of 100.4°F (38°C) on two occasions 24 hours apart
D. Breast engorgement relieved by feeding
CORRECT ANSWER: C. Temperature of 100.4°F (38°C) on two occasions 24 hours
apart
Rationale:A temperature of 100.4°F (38°C) or higher on two separate occasions after
the first 24 hours postpartum is a key indicator of postpartum infection (e.g.,
endometritis, mastitis, UTI) and requires prompt evaluation. Mild perineal discomfort,
lochia rubra for 3-4 days, and engorgement are normal postpartum findings.
Question 9: During a prenatal visit at 28 weeks, a client's fundal height measures 24
cm. What is the nurse's best action?
A. Document the finding as normal variation
B. Schedule an ultrasound to assess fetal growth
C. Advise the client to increase protein intake
D. Reassure the client that measurements vary by examiner
CORRECT ANSWER: B. Schedule an ultrasound to assess fetal growth
, Rationale:Fundal height in centimeters should approximate gestational age in weeks ±2
cm between 20-34 weeks. A measurement of 24 cm at 28 weeks suggests possible fetal
growth restriction, warranting further evaluation via ultrasound. Documentation without
action, dietary advice, or reassurance without assessment could delay diagnosis of
complications.
Question 10: A nurse is caring for a client receiving magnesium sulfate for
preeclampsia. Which assessment finding indicates magnesium toxicity?
A. Urine output of 40 mL/hr
B. Deep tendon reflexes of +2
C. Respiratory rate of 10 breaths per minute
D. Serum magnesium level of 5 mEq/L
CORRECT ANSWER: C. Respiratory rate of 10 breaths per minute
Rationale:Magnesium sulfate depresses the central nervous system; respiratory rate
<12/min is a critical sign of toxicity requiring immediate discontinuation of the infusion
and administration of calcium gluconate. Urine output >30 mL/hr and reflexes +2 are
within acceptable limits; therapeutic magnesium levels for preeclampsia are 4-8
mEq/L, so 5 mEq/L is therapeutic, not toxic.
Question 11: Which intervention is most effective for preventing newborn
hypothermia immediately after birth?
A. Placing the newborn under a radiant warmer
B. Drying the newborn thoroughly and placing skin-to-skin with mother
C. Wrapping the newborn in two warm blankets
D. Delaying bathing for 24 hours
CORRECT ANSWER: B. Drying the newborn thoroughly and placing skin-to-skin with
mother
Rationale:Immediate drying and skin-to-skin contact with the mother is the most
effective strategy to prevent evaporative and convective heat loss, promote
thermoregulation, and support bonding and breastfeeding initiation. Radiant warmers
are used if the newborn requires resuscitation; blankets alone are less effective than
skin-to-skin; delaying bathing is beneficial but secondary to immediate drying and
contact.
Question 12: A client at 36 weeks gestation reports painless, bright red vaginal
bleeding. Which condition should the nurse suspect?
A. Placental abruption
B. Placenta previa
C. Vasa previa
D. Cervical polyp
CORRECT ANSWER: B. Placenta previa
Questions, Answers & Detailed Rationales (Updated 2026) | Prenatal &
Postpartum Care, Labor & Delivery Nursing, Fetal Monitoring & Obstetric
Assessment, Newborn Care & Neonatal Disorders, High-Risk Pregnancy
Complications, Maternal Pharmacology, Family-Centered Care, Patient
Education & NCLEX-Style Clinical Judgment Review
Question 1: A nurse is assessing a pregnant client at 32 weeks gestation. Which
finding should the nurse report to the healthcare provider immediately?
A. Mild ankle edema that resolves with elevation
B. Blood pressure of 148/96 mm Hg on two readings 4 hours apart
C. Weight gain of 1 pound per week
D. Complaints of occasional heartburn after meals
CORRECT ANSWER: B. Blood pressure of 148/96 mm Hg on two readings 4 hours
apart
Rationale:A blood pressure of 148/96 mm Hg on two separate readings meets the
diagnostic criteria for gestational hypertension or preeclampsia, which requires
immediate evaluation to prevent progression to severe complications such as
eclampsia, HELLP syndrome, or placental abruption. Mild edema, appropriate weight
gain, and heartburn are common, expected findings in the third trimester.
Question 2: During the immediate postpartum period, a nurse notes that a client's
fundus is boggy and displaced to the right. What is the priority nursing action?
A. Administer prescribed oxytocin intravenously
B. Assist the client to empty her bladder
C. Massage the fundus vigorously until firm
D. Document the finding and continue monitoring
CORRECT ANSWER: B. Assist the client to empty her bladder
Rationale:A boggy, displaced fundus is often caused by a distended bladder, which
prevents adequate uterine contraction and increases the risk of postpartum
hemorrhage. Assisting the client to void is the priority intervention; fundal massage
should follow only after bladder emptying if the uterus remains boggy. Administering
oxytocin may be indicated later but is not the first action.
Question 3: A newborn is assessed at 1 minute of life with the following: heart rate
90 bpm, slow irregular respirations, some flexion of extremities, grimace to
stimulation, and body pink with blue extremities. What is the newborn's Apgar
score?
A. 4
B. 5
C. 6
D. 7
,CORRECT ANSWER: B. 5
Rationale:The Apgar score assigns 1 point for heart rate <100 bpm (90 bpm), 1 point for
slow/irregular respirations, 1 point for some flexion (muscle tone), 1 point for grimace
(reflex irritability), and 1 point for acrocyanosis (body pink, extremities blue). Total = 5.
This score indicates moderate difficulty requiring supportive care such as stimulation
and oxygen.
Question 4: Which statement by a pregnant client at 10 weeks gestation indicates a
need for further teaching about nutrition?
A. "I will increase my intake of leafy green vegetables for folate."
B. "I should avoid all caffeine during my pregnancy."
C. "I need about 300 additional calories per day during the second trimester."
D. "I will take my prenatal vitamin with a glass of orange juice."
CORRECT ANSWER: B. "I should avoid all caffeine during my pregnancy."
Rationale:Current guidelines suggest limiting caffeine to less than 200 mg per day
(about one 12-oz cup of coffee), not complete avoidance. The other statements reflect
accurate knowledge: folate prevents neural tube defects, caloric needs increase in the
second trimester, and vitamin C enhances iron absorption from prenatal vitamins.
Question 5: A nurse is preparing to administer Rho(D) immune globulin to a
postpartum client. Which assessment finding is essential before administration?
A. Mother's blood type is Rh-negative
B. Newborn's direct Coombs test is negative
C. Mother has no history of Rh sensitization
D. Newborn's blood type is Rh-positive
CORRECT ANSWER: D. Newborn's blood type is Rh-positive
Rationale:Rho(D) immune globulin is indicated only when an Rh-negative mother
delivers an Rh-positive infant, to prevent maternal sensitization to Rh-positive blood
cells. While the mother's Rh-negative status and lack of prior sensitization are
prerequisites, the newborn's Rh-positive status is the critical determinant for
administration.
Question 6: A client in active labor reports sudden, severe abdominal pain and a
sensation of "tearing." The nurse notes fetal bradycardia and maternal tachycardia.
Which complication should the nurse suspect?
A. Placenta previa
B. Uterine rupture
C. Amniotic fluid embolism
D. Cord prolapse
CORRECT ANSWER: B. Uterine rupture
,Rationale:Sudden tearing pain, fetal bradycardia, and maternal tachycardia are classic
signs of uterine rupture, a life-threatening obstetric emergency often associated with
prior cesarean delivery or uterine surgery. Immediate intervention includes preparing for
emergency cesarean birth. Placenta previa presents with painless bleeding; amniotic
fluid embolism causes acute respiratory distress; cord prolapse shows variable
decelerations.
Question 7: Which finding in a 24-hour-old newborn requires immediate nursing
intervention?
A. Respiratory rate of 55 breaths per minute
B. Temperature of 97.8°F (36.6°C) axillary
C. Passage of meconium stool
D. Central cyanosis during crying
CORRECT ANSWER: D. Central cyanosis during crying
Rationale:Central cyanosis (bluish discoloration of the lips, tongue, or trunk) indicates
hypoxemia and possible congenital heart disease or respiratory pathology, requiring
urgent assessment and intervention. A respiratory rate of 55 is within the normal
newborn range (30-60/min); mild hypothermia can be corrected with warming;
meconium passage is expected within 24-48 hours.
Question 8: A nurse is teaching a postpartum client about signs of infection. Which
symptom should the client report immediately?
A. Mild perineal discomfort with sitting
B. Lochia rubra lasting 4 days
C. Temperature of 100.4°F (38°C) on two occasions 24 hours apart
D. Breast engorgement relieved by feeding
CORRECT ANSWER: C. Temperature of 100.4°F (38°C) on two occasions 24 hours
apart
Rationale:A temperature of 100.4°F (38°C) or higher on two separate occasions after
the first 24 hours postpartum is a key indicator of postpartum infection (e.g.,
endometritis, mastitis, UTI) and requires prompt evaluation. Mild perineal discomfort,
lochia rubra for 3-4 days, and engorgement are normal postpartum findings.
Question 9: During a prenatal visit at 28 weeks, a client's fundal height measures 24
cm. What is the nurse's best action?
A. Document the finding as normal variation
B. Schedule an ultrasound to assess fetal growth
C. Advise the client to increase protein intake
D. Reassure the client that measurements vary by examiner
CORRECT ANSWER: B. Schedule an ultrasound to assess fetal growth
, Rationale:Fundal height in centimeters should approximate gestational age in weeks ±2
cm between 20-34 weeks. A measurement of 24 cm at 28 weeks suggests possible fetal
growth restriction, warranting further evaluation via ultrasound. Documentation without
action, dietary advice, or reassurance without assessment could delay diagnosis of
complications.
Question 10: A nurse is caring for a client receiving magnesium sulfate for
preeclampsia. Which assessment finding indicates magnesium toxicity?
A. Urine output of 40 mL/hr
B. Deep tendon reflexes of +2
C. Respiratory rate of 10 breaths per minute
D. Serum magnesium level of 5 mEq/L
CORRECT ANSWER: C. Respiratory rate of 10 breaths per minute
Rationale:Magnesium sulfate depresses the central nervous system; respiratory rate
<12/min is a critical sign of toxicity requiring immediate discontinuation of the infusion
and administration of calcium gluconate. Urine output >30 mL/hr and reflexes +2 are
within acceptable limits; therapeutic magnesium levels for preeclampsia are 4-8
mEq/L, so 5 mEq/L is therapeutic, not toxic.
Question 11: Which intervention is most effective for preventing newborn
hypothermia immediately after birth?
A. Placing the newborn under a radiant warmer
B. Drying the newborn thoroughly and placing skin-to-skin with mother
C. Wrapping the newborn in two warm blankets
D. Delaying bathing for 24 hours
CORRECT ANSWER: B. Drying the newborn thoroughly and placing skin-to-skin with
mother
Rationale:Immediate drying and skin-to-skin contact with the mother is the most
effective strategy to prevent evaporative and convective heat loss, promote
thermoregulation, and support bonding and breastfeeding initiation. Radiant warmers
are used if the newborn requires resuscitation; blankets alone are less effective than
skin-to-skin; delaying bathing is beneficial but secondary to immediate drying and
contact.
Question 12: A client at 36 weeks gestation reports painless, bright red vaginal
bleeding. Which condition should the nurse suspect?
A. Placental abruption
B. Placenta previa
C. Vasa previa
D. Cervical polyp
CORRECT ANSWER: B. Placenta previa
