1. Which of the following is the most appropriate action when a newborn is in
respiratory distress immediately after birth?
A) Administer oxygen via nasal cannula
B) Suction the newborn’s airway
C) Place the newborn in a warmer
D) Start chest compressions
Answer: B) Suction the newborn’s airway
Rationale: Suctioning clears the airway, which is often the primary cause of respiratory distress
in a newborn. Oxygen and warming are also important, but the airway must be cleared first.
2. A nurse is caring for a postpartum client who had a vaginal delivery. Which of
the following should be considered a normal finding for the first 24 hours
postpartum?
A) A fundus 2 cm above the umbilicus
B) Lochia rubra with a small amount of clots
C) Moderate perineal swelling and bruising
D) Bilateral breast engorgement
Answer: B) Lochia rubra with a small amount of clots
Rationale: Lochia rubra is the normal discharge in the first few days postpartum and may
contain small clots. Swelling and engorgement are expected later.
3. A nurse is caring for a newborn who is diagnosed with jaundice. Which of the
following interventions should the nurse prioritize?
A) Monitor bilirubin levels frequently
B) Provide supplemental formula feeding
C) Place the newborn under a phototherapy light
D) Administer vitamin K injection
Answer: C) Place the newborn under a phototherapy light
Rationale: Phototherapy is the primary treatment for jaundice in newborns. It helps reduce
bilirubin levels in the blood.
4. A 2-day postpartum patient is experiencing heavy vaginal bleeding with clots
and is anxious. The nurse should first assess:
,A) The uterus for firmness and position
B) The perineal area for signs of hematoma
C) The blood pressure and pulse
D) The newborn’s feeding pattern
Answer: A) The uterus for firmness and position
Rationale: The first step in assessing postpartum bleeding is to check if the uterus is firm and
positioned correctly. A boggy uterus can cause excessive bleeding.
5. Which of the following is a priority assessment for a newborn with a cleft lip
and palate after surgery?
A) Monitoring the temperature
B) Ensuring proper pain management
C) Assessing the surgical site for infection
D) Ensuring that the infant is feeding effectively
Answer: D) Ensuring that the infant is feeding effectively
Rationale: Infants with cleft lip and palate often have difficulty feeding. Proper feeding
techniques are crucial post-surgery.
6. A nurse is preparing a client for a cesarean section. Which of the following
actions should the nurse take?
A) Administer a mild sedative to the client
B) Verify that the client has signed the informed consent
C) Shave the client’s pubic area immediately before surgery
D) Begin intravenous (IV) fluids only after anesthesia
Answer: B) Verify that the client has signed the informed consent
Rationale: Informed consent is required before surgery. This should be confirmed prior to any
procedure or intervention.
7. A pregnant client at 28 weeks gestation reports feeling faint and dizzy when
lying flat on her back. What is the nurse’s best action?
A) Tell the client to lie on her left side
B) Administer oxygen via nasal cannula
C) Encourage the client to drink fluids
D) Notify the healthcare provider immediately
, Answer: A) Tell the client to lie on her left side
Rationale: The client is likely experiencing supine hypotensive syndrome. Lying on the left side
helps improve blood flow to the uterus and improves symptoms.
8. Which of the following is an appropriate nursing intervention for a client in
early labor?
A) Administer an epidural analgesic
B) Encourage ambulation to promote labor progress
C) Perform vaginal exams every 2 hours
D) Limit oral intake to clear liquids
Answer: B) Encourage ambulation to promote labor progress
Rationale: Ambulation can help stimulate labor progress and reduce discomfort during early
labor.
9. A newborn is being monitored for hypoglycemia. Which of the following
findings would be most indicative of hypoglycemia in the first hours of life?
A) Crying and irritability
B) Jitteriness and poor feeding
C) Respiratory distress
D) A temperature of 98°F (36.7°C)
Answer: B) Jitteriness and poor feeding
Rationale: Jitteriness and poor feeding are common signs of hypoglycemia in newborns.
Immediate treatment is required.
10. A pregnant client at 40 weeks gestation is experiencing contractions every 2-3
minutes and has a cervical dilation of 7 cm. What stage of labor is this client in?
A) First stage, latent phase
B) First stage, active phase
C) Second stage
D) Third stage
Answer: B) First stage, active phase
Rationale: The active phase of the first stage of labor is characterized by regular contractions
and cervical dilation between 6-10 cm.
respiratory distress immediately after birth?
A) Administer oxygen via nasal cannula
B) Suction the newborn’s airway
C) Place the newborn in a warmer
D) Start chest compressions
Answer: B) Suction the newborn’s airway
Rationale: Suctioning clears the airway, which is often the primary cause of respiratory distress
in a newborn. Oxygen and warming are also important, but the airway must be cleared first.
2. A nurse is caring for a postpartum client who had a vaginal delivery. Which of
the following should be considered a normal finding for the first 24 hours
postpartum?
A) A fundus 2 cm above the umbilicus
B) Lochia rubra with a small amount of clots
C) Moderate perineal swelling and bruising
D) Bilateral breast engorgement
Answer: B) Lochia rubra with a small amount of clots
Rationale: Lochia rubra is the normal discharge in the first few days postpartum and may
contain small clots. Swelling and engorgement are expected later.
3. A nurse is caring for a newborn who is diagnosed with jaundice. Which of the
following interventions should the nurse prioritize?
A) Monitor bilirubin levels frequently
B) Provide supplemental formula feeding
C) Place the newborn under a phototherapy light
D) Administer vitamin K injection
Answer: C) Place the newborn under a phototherapy light
Rationale: Phototherapy is the primary treatment for jaundice in newborns. It helps reduce
bilirubin levels in the blood.
4. A 2-day postpartum patient is experiencing heavy vaginal bleeding with clots
and is anxious. The nurse should first assess:
,A) The uterus for firmness and position
B) The perineal area for signs of hematoma
C) The blood pressure and pulse
D) The newborn’s feeding pattern
Answer: A) The uterus for firmness and position
Rationale: The first step in assessing postpartum bleeding is to check if the uterus is firm and
positioned correctly. A boggy uterus can cause excessive bleeding.
5. Which of the following is a priority assessment for a newborn with a cleft lip
and palate after surgery?
A) Monitoring the temperature
B) Ensuring proper pain management
C) Assessing the surgical site for infection
D) Ensuring that the infant is feeding effectively
Answer: D) Ensuring that the infant is feeding effectively
Rationale: Infants with cleft lip and palate often have difficulty feeding. Proper feeding
techniques are crucial post-surgery.
6. A nurse is preparing a client for a cesarean section. Which of the following
actions should the nurse take?
A) Administer a mild sedative to the client
B) Verify that the client has signed the informed consent
C) Shave the client’s pubic area immediately before surgery
D) Begin intravenous (IV) fluids only after anesthesia
Answer: B) Verify that the client has signed the informed consent
Rationale: Informed consent is required before surgery. This should be confirmed prior to any
procedure or intervention.
7. A pregnant client at 28 weeks gestation reports feeling faint and dizzy when
lying flat on her back. What is the nurse’s best action?
A) Tell the client to lie on her left side
B) Administer oxygen via nasal cannula
C) Encourage the client to drink fluids
D) Notify the healthcare provider immediately
, Answer: A) Tell the client to lie on her left side
Rationale: The client is likely experiencing supine hypotensive syndrome. Lying on the left side
helps improve blood flow to the uterus and improves symptoms.
8. Which of the following is an appropriate nursing intervention for a client in
early labor?
A) Administer an epidural analgesic
B) Encourage ambulation to promote labor progress
C) Perform vaginal exams every 2 hours
D) Limit oral intake to clear liquids
Answer: B) Encourage ambulation to promote labor progress
Rationale: Ambulation can help stimulate labor progress and reduce discomfort during early
labor.
9. A newborn is being monitored for hypoglycemia. Which of the following
findings would be most indicative of hypoglycemia in the first hours of life?
A) Crying and irritability
B) Jitteriness and poor feeding
C) Respiratory distress
D) A temperature of 98°F (36.7°C)
Answer: B) Jitteriness and poor feeding
Rationale: Jitteriness and poor feeding are common signs of hypoglycemia in newborns.
Immediate treatment is required.
10. A pregnant client at 40 weeks gestation is experiencing contractions every 2-3
minutes and has a cervical dilation of 7 cm. What stage of labor is this client in?
A) First stage, latent phase
B) First stage, active phase
C) Second stage
D) Third stage
Answer: B) First stage, active phase
Rationale: The active phase of the first stage of labor is characterized by regular contractions
and cervical dilation between 6-10 cm.
