1
220 VERIFIED QUESTIONS AND DETAILED RATIONALE FROM
MATERNITY AND PEDIATRIC NURSING – (5TH EDITION, EXAM
QUESTIONS) – (RICCI, KYLE & CARMAN) – (CH. 1–51) 100%
CORRECT
1
A 32-year-old G2P1 at 37 weeks’ gestation presents to triage reporting a sudden,
painless gush of fluid while getting out of bed; she notes decreased fetal movement
since the event. On exam her temperature is 98.6°F and fetal heart rate is 150 bpm.
The nurse’s immediate priority is to:
A. Obtain a urine sample for culture.
B. Assess fetal heart rate continuously and check for cord prolapse.
C. Instruct client to ambulate and monitor contractions at home.
D. Give betamethasone for fetal lung maturity.
Answer: B. Assess fetal heart rate continuously and check for cord prolapse.
Rationale: Sudden gush of fluid suggests rupture of membranes; immediate
continuous fetal monitoring and assessment for cord prolapse are essential to
determine fetal status and urgency for delivery or interventions. Other actions (e.g.,
cultures, steroids) are secondary.
, 2
2
A 19-year-old primigravida at 28 weeks with a history of chronic hypertension
reports sudden onset of severe headache, visual disturbances, and right upper
quadrant pain during her prenatal visit; BP is 170/110 mm Hg. The nurse
recognizes these findings as most consistent with:
A. Ectopic pregnancy.
B. Severe preeclampsia with possible HELLP syndrome.
C. Hyperemesis gravidarum.
D. Placenta previa.
Answer: B. Severe preeclampsia with possible HELLP syndrome.
Rationale: New-onset severe hypertension after 20 weeks with headache, visual
changes, and RUQ pain suggests severe preeclampsia and may indicate hepatic
involvement (HELLP). Immediate evaluation and stabilization are required.
3
A postpartum woman 6 hours after vaginal birth reports sudden soaking through
her peri-pad and lightheadedness when she stands; her fundus is boggy and
displaced to the right of midline, and pulse is 118 bpm. The nurse should first:
A. Massage the fundus and assess for retained placenta or bladder distention.
B. Notify the provider to prepare for return to the OR.
, 3
C. Encourage oral fluids and re-evaluate in 30 minutes.
D. Apply cold packs to the perineum and measure lochia.
Answer: A. Massage the fundus and assess for retained placenta or bladder
distention.
Rationale: A boggy, displaced fundus and excessive bleeding suggest uterine
atony often due to bladder distention or retained products; fundal massage and
bladder assessment are immediate nursing interventions to control bleeding.
4
A 6-month-old infant is brought to the clinic with a 2-day history of cough and
low-grade fever. On exam the infant has intercostal retractions, nasal flaring,
respiratory rate 66/min, and oxygen saturation 92% on room air. The nurse
recognizes these findings as:
A. Mild, uncomplicated upper respiratory infection—discharge with oral fluids.
B. Signs of respiratory distress requiring further assessment and possible
hospitalization.
C. Normal findings for teething—provide reassurance.
D. Indication for immediate intubation in the clinic.
Answer: B. Signs of respiratory distress requiring further assessment and
possible hospitalization.
, 4
Rationale: Increased RR >60, retractions, and nasal flaring are signs of respiratory
distress in infants and warrant prompt assessment, oxygen support, and possible
hospital admission; immediate intubation is not always required.
5
A 24-year-old woman in active labor (5 cm dilated) with history of asthma asks for
pain relief options; she uses albuterol inhaler at home. Platelets are within normal
range and she requests an epidural. The nurse’s best response is to:
A. Explain that epidural anesthesia is contraindicated for asthmatics.
B. Inform her that epidural anesthesia is an option and notify anesthesia to discuss
placement.
C. Advise that only general anesthesia is available for labor pain in this situation.
D. Offer only IV opioids because inhaled bronchodilators interact with epidurals.
Answer: B. Inform her that epidural anesthesia is an option and notify
anesthesia to discuss placement.
Rationale: Asthma is not a contraindication to epidural anesthesia; with normal
labs and platelets, an epidural is appropriate. The nurse should coordinate with
anesthesia and provide education on risks/benefits.
6
220 VERIFIED QUESTIONS AND DETAILED RATIONALE FROM
MATERNITY AND PEDIATRIC NURSING – (5TH EDITION, EXAM
QUESTIONS) – (RICCI, KYLE & CARMAN) – (CH. 1–51) 100%
CORRECT
1
A 32-year-old G2P1 at 37 weeks’ gestation presents to triage reporting a sudden,
painless gush of fluid while getting out of bed; she notes decreased fetal movement
since the event. On exam her temperature is 98.6°F and fetal heart rate is 150 bpm.
The nurse’s immediate priority is to:
A. Obtain a urine sample for culture.
B. Assess fetal heart rate continuously and check for cord prolapse.
C. Instruct client to ambulate and monitor contractions at home.
D. Give betamethasone for fetal lung maturity.
Answer: B. Assess fetal heart rate continuously and check for cord prolapse.
Rationale: Sudden gush of fluid suggests rupture of membranes; immediate
continuous fetal monitoring and assessment for cord prolapse are essential to
determine fetal status and urgency for delivery or interventions. Other actions (e.g.,
cultures, steroids) are secondary.
, 2
2
A 19-year-old primigravida at 28 weeks with a history of chronic hypertension
reports sudden onset of severe headache, visual disturbances, and right upper
quadrant pain during her prenatal visit; BP is 170/110 mm Hg. The nurse
recognizes these findings as most consistent with:
A. Ectopic pregnancy.
B. Severe preeclampsia with possible HELLP syndrome.
C. Hyperemesis gravidarum.
D. Placenta previa.
Answer: B. Severe preeclampsia with possible HELLP syndrome.
Rationale: New-onset severe hypertension after 20 weeks with headache, visual
changes, and RUQ pain suggests severe preeclampsia and may indicate hepatic
involvement (HELLP). Immediate evaluation and stabilization are required.
3
A postpartum woman 6 hours after vaginal birth reports sudden soaking through
her peri-pad and lightheadedness when she stands; her fundus is boggy and
displaced to the right of midline, and pulse is 118 bpm. The nurse should first:
A. Massage the fundus and assess for retained placenta or bladder distention.
B. Notify the provider to prepare for return to the OR.
, 3
C. Encourage oral fluids and re-evaluate in 30 minutes.
D. Apply cold packs to the perineum and measure lochia.
Answer: A. Massage the fundus and assess for retained placenta or bladder
distention.
Rationale: A boggy, displaced fundus and excessive bleeding suggest uterine
atony often due to bladder distention or retained products; fundal massage and
bladder assessment are immediate nursing interventions to control bleeding.
4
A 6-month-old infant is brought to the clinic with a 2-day history of cough and
low-grade fever. On exam the infant has intercostal retractions, nasal flaring,
respiratory rate 66/min, and oxygen saturation 92% on room air. The nurse
recognizes these findings as:
A. Mild, uncomplicated upper respiratory infection—discharge with oral fluids.
B. Signs of respiratory distress requiring further assessment and possible
hospitalization.
C. Normal findings for teething—provide reassurance.
D. Indication for immediate intubation in the clinic.
Answer: B. Signs of respiratory distress requiring further assessment and
possible hospitalization.
, 4
Rationale: Increased RR >60, retractions, and nasal flaring are signs of respiratory
distress in infants and warrant prompt assessment, oxygen support, and possible
hospital admission; immediate intubation is not always required.
5
A 24-year-old woman in active labor (5 cm dilated) with history of asthma asks for
pain relief options; she uses albuterol inhaler at home. Platelets are within normal
range and she requests an epidural. The nurse’s best response is to:
A. Explain that epidural anesthesia is contraindicated for asthmatics.
B. Inform her that epidural anesthesia is an option and notify anesthesia to discuss
placement.
C. Advise that only general anesthesia is available for labor pain in this situation.
D. Offer only IV opioids because inhaled bronchodilators interact with epidurals.
Answer: B. Inform her that epidural anesthesia is an option and notify
anesthesia to discuss placement.
Rationale: Asthma is not a contraindication to epidural anesthesia; with normal
labs and platelets, an epidural is appropriate. The nurse should coordinate with
anesthesia and provide education on risks/benefits.
6
