1. A nurse is caring for a client in labor who is experiencing variable
decelerations on the fetal heart rate (FHR) monitor. What is the most
appropriate nursing intervention?
a) Administer oxygen
b) Change maternal position
c) Increase the IV fluids
d) Apply a tocolytic medication
Answer: b) Change maternal position
Rationale: Variable decelerations are often caused by umbilical cord compression. Changing the
maternal position can relieve pressure on the umbilical cord, improving fetal oxygenation and
relieving the decelerations.
2. A nurse is assessing a newborn immediately after birth. Which of the following
is the most important assessment to make within the first minute of life?
a) Apgar score
b) Respiratory rate
c) Reflexes
d) Weight and length
Answer: a) Apgar score
Rationale: The Apgar score assesses the newborn’s immediate adaptation to extrauterine life by
evaluating heart rate, respiratory effort, muscle tone, reflex irritability, and color at 1 and 5
minutes after birth.
3. A pregnant client at 36 weeks gestation presents with a blood pressure of
160/110 mmHg and proteinuria. What is the most likely diagnosis?
a) Gestational hypertension
b) Preeclampsia
c) Chronic hypertension
d) Eclampsia
Answer: b) Preeclampsia
,Rationale: Preeclampsia is characterized by hypertension (above 140/90 mmHg) and proteinuria
after 20 weeks of pregnancy. It can lead to serious complications if untreated, such as organ
damage.
4. Which of the following is a priority nursing intervention when caring for a
client with a diagnosis of placenta previa?
a) Administer magnesium sulfate
b) Prepare for immediate cesarean delivery
c) Perform a vaginal exam
d) Encourage bed rest
Answer: b) Prepare for immediate cesarean delivery
Rationale: Placenta previa occurs when the placenta is abnormally located near or over the
cervix, increasing the risk of hemorrhage during labor. A cesarean delivery is typically required
to avoid complications.
5. A nurse is teaching a client about breastfeeding. Which of the following should
the nurse include as a sign of effective breastfeeding?
a) The infant falls asleep after 5 minutes of sucking.
b) The infant has 6 to 8 wet diapers per day.
c) The infant’s stools are consistently green.
d) The infant appears to be lethargic and unresponsive after feeding.
Answer: b) The infant has 6 to 8 wet diapers per day.
Rationale: Adequate breastfeeding is indicated by the infant having 6 to 8 wet diapers a day,
which shows they are getting enough milk.
6. A nurse is assessing a newborn and notes a high-pitched cry, poor feeding, and
lethargy. What should the nurse do first?
a) Administer a feeding.
b) Notify the healthcare provider.
c) Perform a thorough physical assessment.
d) Offer the infant a pacifier.
Answer: b) Notify the healthcare provider.
, Rationale: A high-pitched cry, poor feeding, and lethargy may indicate a serious condition such
as a neurological disorder or infection, and the healthcare provider should be notified
immediately.
7. A nurse is caring for a postpartum client who is experiencing heavy lochia
rubra with clots. Which action should the nurse take?
a) Massage the fundus.
b) Increase the IV fluid rate.
c) Prepare the client for a hysterectomy.
d) Administer oxygen.
Answer: a) Massage the fundus.
Rationale: Heavy lochia with clots can indicate uterine atony. Massaging the fundus helps
stimulate uterine contraction and helps reduce bleeding.
8. A client at 8 weeks gestation is diagnosed with hyperemesis gravidarum. What
is the most appropriate intervention for the nurse to include in the care plan?
a) Administer antiemetic medications
b) Encourage the client to drink fluids with meals
c) Recommend a high-protein, low-fat diet
d) Suggest increasing caffeine intake
Answer: a) Administer antiemetic medications
Rationale: Hyperemesis gravidarum is characterized by severe nausea and vomiting in
pregnancy, which may require antiemetic medications to prevent dehydration and electrolyte
imbalances.
9. A nurse is teaching a client about the signs of preterm labor. Which of the
following should the nurse include in the teaching?
a) Decreased fetal movement
b) Feeling of pelvic pressure
c) Severe headache
d) Swelling of the hands and feet
Answer: b) Feeling of pelvic pressure
decelerations on the fetal heart rate (FHR) monitor. What is the most
appropriate nursing intervention?
a) Administer oxygen
b) Change maternal position
c) Increase the IV fluids
d) Apply a tocolytic medication
Answer: b) Change maternal position
Rationale: Variable decelerations are often caused by umbilical cord compression. Changing the
maternal position can relieve pressure on the umbilical cord, improving fetal oxygenation and
relieving the decelerations.
2. A nurse is assessing a newborn immediately after birth. Which of the following
is the most important assessment to make within the first minute of life?
a) Apgar score
b) Respiratory rate
c) Reflexes
d) Weight and length
Answer: a) Apgar score
Rationale: The Apgar score assesses the newborn’s immediate adaptation to extrauterine life by
evaluating heart rate, respiratory effort, muscle tone, reflex irritability, and color at 1 and 5
minutes after birth.
3. A pregnant client at 36 weeks gestation presents with a blood pressure of
160/110 mmHg and proteinuria. What is the most likely diagnosis?
a) Gestational hypertension
b) Preeclampsia
c) Chronic hypertension
d) Eclampsia
Answer: b) Preeclampsia
,Rationale: Preeclampsia is characterized by hypertension (above 140/90 mmHg) and proteinuria
after 20 weeks of pregnancy. It can lead to serious complications if untreated, such as organ
damage.
4. Which of the following is a priority nursing intervention when caring for a
client with a diagnosis of placenta previa?
a) Administer magnesium sulfate
b) Prepare for immediate cesarean delivery
c) Perform a vaginal exam
d) Encourage bed rest
Answer: b) Prepare for immediate cesarean delivery
Rationale: Placenta previa occurs when the placenta is abnormally located near or over the
cervix, increasing the risk of hemorrhage during labor. A cesarean delivery is typically required
to avoid complications.
5. A nurse is teaching a client about breastfeeding. Which of the following should
the nurse include as a sign of effective breastfeeding?
a) The infant falls asleep after 5 minutes of sucking.
b) The infant has 6 to 8 wet diapers per day.
c) The infant’s stools are consistently green.
d) The infant appears to be lethargic and unresponsive after feeding.
Answer: b) The infant has 6 to 8 wet diapers per day.
Rationale: Adequate breastfeeding is indicated by the infant having 6 to 8 wet diapers a day,
which shows they are getting enough milk.
6. A nurse is assessing a newborn and notes a high-pitched cry, poor feeding, and
lethargy. What should the nurse do first?
a) Administer a feeding.
b) Notify the healthcare provider.
c) Perform a thorough physical assessment.
d) Offer the infant a pacifier.
Answer: b) Notify the healthcare provider.
, Rationale: A high-pitched cry, poor feeding, and lethargy may indicate a serious condition such
as a neurological disorder or infection, and the healthcare provider should be notified
immediately.
7. A nurse is caring for a postpartum client who is experiencing heavy lochia
rubra with clots. Which action should the nurse take?
a) Massage the fundus.
b) Increase the IV fluid rate.
c) Prepare the client for a hysterectomy.
d) Administer oxygen.
Answer: a) Massage the fundus.
Rationale: Heavy lochia with clots can indicate uterine atony. Massaging the fundus helps
stimulate uterine contraction and helps reduce bleeding.
8. A client at 8 weeks gestation is diagnosed with hyperemesis gravidarum. What
is the most appropriate intervention for the nurse to include in the care plan?
a) Administer antiemetic medications
b) Encourage the client to drink fluids with meals
c) Recommend a high-protein, low-fat diet
d) Suggest increasing caffeine intake
Answer: a) Administer antiemetic medications
Rationale: Hyperemesis gravidarum is characterized by severe nausea and vomiting in
pregnancy, which may require antiemetic medications to prevent dehydration and electrolyte
imbalances.
9. A nurse is teaching a client about the signs of preterm labor. Which of the
following should the nurse include in the teaching?
a) Decreased fetal movement
b) Feeling of pelvic pressure
c) Severe headache
d) Swelling of the hands and feet
Answer: b) Feeling of pelvic pressure
