NURSING 421 MATERNAL NEWBORN
QUESTIONS AND ANSWERS WITH RATIONALES
2023-2024 LATEST UPDATE- ACTUAL EXAM
PRACTICE QUESTIONS| A+ GRADED|
A nurse is caring for a client who is at 36 weeks of gestation and who has a
suspected placenta previa. Which of the following findings support this diagnosis?
Painless red vaginal bleeding
Answer Rationale:
Placenta previa is a condition of pregnancy when the placenta implants in the
lower part of the uterus, partly or completely obstructing the cervical os (outlet to
the vagina). Bright red, painless vaginal bleeding occurs in the second and third
trimester.
A nurse is caring for a client who is 1 hr postpartum and observes a large amount
of lochia rubra and several small clots on the client's perineal pad. The fundus is
midline and firm at the umbilicus. Which of the following actions should the nurse
take?
Document the findings and continue to monitor the client.
Answer Rationale:
These are expected findings. At 1 hr postpartum, lochia rubra should be
intermittent and associated with uterine contractions. The volume of lochia
resembles that of a heavy menstrual period. Small clots are common. The nurse
should document the findings and continue to monitor the client.
A nurse is caring for a newborn immediately following birth. After assuring a
patent airway, what is the priority nursing action?
Dry the skin.
Answer Rationale:
The newborn should be thoroughly dried, covered with a warm blanket, placed on
the mother’s abdomen, and a cap applied to the newborn’s head to prevent cold
stress. The newborn responds to the cooler environment by increasing his
respiratory rate, which can lead to respiratory distress. Based on Maslow’s
hierarchy of needs, this is the most important nursing action after securing the
airway.
A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The
,client reports urinary frequency and asks if this will continue until delivery. Which
of the following responses should the nurse make?
"It occurs during the first trimester and near the end of the pregnancy."
Answer Rationale:
Urinary frequency is due to increased bladder sensitivity during the first trimester
and recurs near the end of the pregnancy as the enlarging uterus places pressure on
the bladder.
A nurse is caring for a client during the first trimester of pregnancy. After
reviewing the client's blood work, the nurse notices she does not have immunity to
rubella. Which of the following times should the nurse understand is recommended
for rubella immunization?
Shortly after giving birth
Answer Rationale:
The rubella immunization should be offered to the client following birth,
preferably prior to discharge from the hospital. This prevents the client from
contracting rubella during the current or subsequent pregnancies, which would put
her fetus at risk for rubella syndrome.
A nurse is caring for a client who just delivered a newborn. Following the delivery,
which nursing action should be done first to care for the newborn?
Clear the respiratory tract.
Answer Rationale:
Clearing the airway of the infant is the first action the nurse should take
immediately following delivery.
A nurse in a family planning clinic is caring for a 17-year-old female client who is
requesting oral contraceptives. The client states that she is nervous because she has
never had a pelvic examination. Which of the following responses should the nurse
make?
"What part of the exam makes you most nervous?"
Answer Rationale:
This therapeutic response recognizes the client's feelings. It also uses the
therapeutic technique of clarification to encourage the client to tell the nurse more
about her concerns.
,A nurse in labor and delivery is caring for a client. Following delivery of the
placenta, the nurse examines the umbilical cord. Which of the following vessels
should the nurse expect to observe in the umbilical cord?
Two arteries and one vein
Answer Rationale:
The vein carried the oxygenated, nutrient-rich blood from the placenta to the fetus,
and the two arteries returned the blood to the placenta.
A nurse is caring for a client who is considering several methods of contraception.
Which of the following methods of contraception should the nurse identify as
being most reliable?
An intrauterine device (IUD)
Answer Rationale:
An IUD is found to have a failure rate of less than 1 in 100 users, which makes it
one of the most reliable methods of contraception.
A nurse is caring for an antepartum client whose laboratory findings indicate a
negative rubella titer. Which of the following is the correct interpretation of this
data?
The client requires a rubella immunization following delivery.
Answer Rationale:
A negative rubella titer indicates that the client is susceptible to the rubella virus
and needs vaccination following delivery. Immunization during pregnancy is
contraindicated because of possible injury to the developing fetus. Following
rubella immunization, the client should be cautioned not to conceive for 1 month.
A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a
large amount of painless, bright red vaginal bleeding. The client is placed on a fetal
monitor indicating a regular fetal heart rate of 138/min and no uterine contractions.
The client's vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min,
respiratory rate 24/min, and temperature 36.4° C (97.6° F). Which of the following
is the priority nursing action?
Initiate IV access.
Answer Rationale:
, Insertion of a large-bore IV catheter is the priority nursing action. The client is
losing blood rapidly, has hypotension, and tachycardia. IV access will allow IV
fluids and blood to be administered quickly if hypovolemia develops.
A nurse in a prenatal clinic is caring for a client who is suspected of having a
hydatidiform mole. Which of the following findings should the nurse expect to
observe in this client?
Excessive uterine enlargement
Answer Rationale:
A hydatidiform mole is a rare tumor that forms inside the uterus at the beginning of
a pregnancy and results in the over-production of tissue that would normally
develop into the placenta. This tissue consists of fluid-filled vesicles. A rapidly
enlarging uterus is a classic finding in clients who have a molar pregnancy. It is
often accompanied by severe nausea and vomiting, elevated human chorionic
gonadotropin levels, signs of hyperthyroidism, and early onset of preeclampsia.
A nurse is caring for a new mother who is concerned that her newborn's eyes cross.
Which of the following statements is a therapeutic response by the nurse?
"This occurs because newborns lack muscle control to regulate eye
movement."
Answer Rationale:
This addresses the client’s concerns because it provides information that addresses
her concerns. The eyes of newborns are structurally incomplete and muscle control
is not fully developed for 3 months.
A nurse is caring for a client who is having a nonstress test performed. The fetal
heart rate (FHR) is 130 to 150/min, but there has been no fetal movement for 15
min. Which of the following actions should the nurse perform?
Offer the client a snack of orange juice and crackers.
Answer Rationale:
A nonstress test depends upon fetal movement, and this fetus is most likely asleep.
Most fetuses are more active after meals due to the increase in the mother's blood
sugar. Giving the mother a snack will promote fetal movement.
QUESTIONS AND ANSWERS WITH RATIONALES
2023-2024 LATEST UPDATE- ACTUAL EXAM
PRACTICE QUESTIONS| A+ GRADED|
A nurse is caring for a client who is at 36 weeks of gestation and who has a
suspected placenta previa. Which of the following findings support this diagnosis?
Painless red vaginal bleeding
Answer Rationale:
Placenta previa is a condition of pregnancy when the placenta implants in the
lower part of the uterus, partly or completely obstructing the cervical os (outlet to
the vagina). Bright red, painless vaginal bleeding occurs in the second and third
trimester.
A nurse is caring for a client who is 1 hr postpartum and observes a large amount
of lochia rubra and several small clots on the client's perineal pad. The fundus is
midline and firm at the umbilicus. Which of the following actions should the nurse
take?
Document the findings and continue to monitor the client.
Answer Rationale:
These are expected findings. At 1 hr postpartum, lochia rubra should be
intermittent and associated with uterine contractions. The volume of lochia
resembles that of a heavy menstrual period. Small clots are common. The nurse
should document the findings and continue to monitor the client.
A nurse is caring for a newborn immediately following birth. After assuring a
patent airway, what is the priority nursing action?
Dry the skin.
Answer Rationale:
The newborn should be thoroughly dried, covered with a warm blanket, placed on
the mother’s abdomen, and a cap applied to the newborn’s head to prevent cold
stress. The newborn responds to the cooler environment by increasing his
respiratory rate, which can lead to respiratory distress. Based on Maslow’s
hierarchy of needs, this is the most important nursing action after securing the
airway.
A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The
,client reports urinary frequency and asks if this will continue until delivery. Which
of the following responses should the nurse make?
"It occurs during the first trimester and near the end of the pregnancy."
Answer Rationale:
Urinary frequency is due to increased bladder sensitivity during the first trimester
and recurs near the end of the pregnancy as the enlarging uterus places pressure on
the bladder.
A nurse is caring for a client during the first trimester of pregnancy. After
reviewing the client's blood work, the nurse notices she does not have immunity to
rubella. Which of the following times should the nurse understand is recommended
for rubella immunization?
Shortly after giving birth
Answer Rationale:
The rubella immunization should be offered to the client following birth,
preferably prior to discharge from the hospital. This prevents the client from
contracting rubella during the current or subsequent pregnancies, which would put
her fetus at risk for rubella syndrome.
A nurse is caring for a client who just delivered a newborn. Following the delivery,
which nursing action should be done first to care for the newborn?
Clear the respiratory tract.
Answer Rationale:
Clearing the airway of the infant is the first action the nurse should take
immediately following delivery.
A nurse in a family planning clinic is caring for a 17-year-old female client who is
requesting oral contraceptives. The client states that she is nervous because she has
never had a pelvic examination. Which of the following responses should the nurse
make?
"What part of the exam makes you most nervous?"
Answer Rationale:
This therapeutic response recognizes the client's feelings. It also uses the
therapeutic technique of clarification to encourage the client to tell the nurse more
about her concerns.
,A nurse in labor and delivery is caring for a client. Following delivery of the
placenta, the nurse examines the umbilical cord. Which of the following vessels
should the nurse expect to observe in the umbilical cord?
Two arteries and one vein
Answer Rationale:
The vein carried the oxygenated, nutrient-rich blood from the placenta to the fetus,
and the two arteries returned the blood to the placenta.
A nurse is caring for a client who is considering several methods of contraception.
Which of the following methods of contraception should the nurse identify as
being most reliable?
An intrauterine device (IUD)
Answer Rationale:
An IUD is found to have a failure rate of less than 1 in 100 users, which makes it
one of the most reliable methods of contraception.
A nurse is caring for an antepartum client whose laboratory findings indicate a
negative rubella titer. Which of the following is the correct interpretation of this
data?
The client requires a rubella immunization following delivery.
Answer Rationale:
A negative rubella titer indicates that the client is susceptible to the rubella virus
and needs vaccination following delivery. Immunization during pregnancy is
contraindicated because of possible injury to the developing fetus. Following
rubella immunization, the client should be cautioned not to conceive for 1 month.
A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a
large amount of painless, bright red vaginal bleeding. The client is placed on a fetal
monitor indicating a regular fetal heart rate of 138/min and no uterine contractions.
The client's vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min,
respiratory rate 24/min, and temperature 36.4° C (97.6° F). Which of the following
is the priority nursing action?
Initiate IV access.
Answer Rationale:
, Insertion of a large-bore IV catheter is the priority nursing action. The client is
losing blood rapidly, has hypotension, and tachycardia. IV access will allow IV
fluids and blood to be administered quickly if hypovolemia develops.
A nurse in a prenatal clinic is caring for a client who is suspected of having a
hydatidiform mole. Which of the following findings should the nurse expect to
observe in this client?
Excessive uterine enlargement
Answer Rationale:
A hydatidiform mole is a rare tumor that forms inside the uterus at the beginning of
a pregnancy and results in the over-production of tissue that would normally
develop into the placenta. This tissue consists of fluid-filled vesicles. A rapidly
enlarging uterus is a classic finding in clients who have a molar pregnancy. It is
often accompanied by severe nausea and vomiting, elevated human chorionic
gonadotropin levels, signs of hyperthyroidism, and early onset of preeclampsia.
A nurse is caring for a new mother who is concerned that her newborn's eyes cross.
Which of the following statements is a therapeutic response by the nurse?
"This occurs because newborns lack muscle control to regulate eye
movement."
Answer Rationale:
This addresses the client’s concerns because it provides information that addresses
her concerns. The eyes of newborns are structurally incomplete and muscle control
is not fully developed for 3 months.
A nurse is caring for a client who is having a nonstress test performed. The fetal
heart rate (FHR) is 130 to 150/min, but there has been no fetal movement for 15
min. Which of the following actions should the nurse perform?
Offer the client a snack of orange juice and crackers.
Answer Rationale:
A nonstress test depends upon fetal movement, and this fetus is most likely asleep.
Most fetuses are more active after meals due to the increase in the mother's blood
sugar. Giving the mother a snack will promote fetal movement.
