Test Bank for Safe Maternity and Pediatric Nursing Care 3rd Edition
(F.A Davis , 2026) by Luanne Linnard Palmer,
, INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING
1. A nurse is caring for a client in the active phase of labor. Which finding would
require immediate intervention?
A) Cervical dilation from 4 to 6 cm over 4 hours
B) Contractions every 3 minutes lasting 60 seconds
C) Fetal heart rate baseline of 150 bpm with moderate variability
D) Fetal heart rate decelerations that are late and recurrent
Rationale: Late decelerations indicate uteroplacental insufficiency and require
immediate intervention to improve placental blood flow and fetal oxygenation.
Options A and B are normal active phase findings; option C is a normal fetal heart
rate pattern.
2. A primigravida at 39 weeks gestation is admitted with contractions every 5
minutes. Her cervix is 3 cm dilated, 50% effaced, and the fetal head is at -1 station.
The nurse documents this as:
A) Latent phase of labor
B) Active phase of labor
C) Transition phase of labor
D) Early deceleration phase
*Rationale: The latent phase is 0-3 cm, active phase is 4-7 cm, and transition is 8-10 cm.
At 3 cm with regular contractions, the client is at the end of latent/beginning of active
phase, but standard documentation places 3 cm in latent. CORRECTION: Actually, 3 cm
is the end of latent phase (0-3 cm). The correct answer should be latent phase. However,
many texts consider 3 cm as transition to active. To align with safe nursing care,
recognize that active phase begins at 4-6 cm. Thus at 3 cm, the client is in latent phase.*
(Note: I'll correct the above for accuracy)
Corrected Q2: A primigravida at 39 weeks gestation is admitted with contractions
every 5 minutes. Her cervix is 3 cm dilated, 50% effaced, and the fetal head is at -1
station. The nurse documents this as:
A) Latent phase of labor
B) Active phase of labor
C) Transition phase of labor
D) Second stage of labor
, *Rationale: The latent (early) phase of labor is characterized by cervical dilation from 0-3
cm. The active phase begins at 4 cm, transition at 8-10 cm, and second stage is
complete dilation (10 cm) with pushing.*
3. A postpartum client reports a firm, midline fundus but heavy lochia with large
clots. The nurse's priority action is to:
A) Encourage ambulation to promote drainage
B) Administer prescribed oxytocin
C) Assess for bladder distention
D) Perform fundal massage continuously
Rationale: A firm fundus with heavy bleeding and clots suggests retained products
or bladder distention displacing the uterus. Bladder distention prevents uterine
contraction. The nurse should first assess for bladder distention and have the client
void before other interventions.
4. Which finding in a newborn at 4 hours of life requires immediate notification of
the healthcare provider?
A) Acrocyanosis of hands and feet
B) Respiratory rate of 60 breaths per minute
C) Apical heart rate of 160 bpm while crying
D) Grunting with nasal flaring
*Rationale: Grunting, nasal flaring, and retractions are signs of respiratory distress in a
newborn. Acrocyanosis is normal in the first 24 hours. A respiratory rate of 60 is normal
(normal range 30-60). Heart rate 160 is within normal limits (110-160, can increase with
crying).*
5. A nurse is teaching a prenatal class about signs of preterm labor. Which
statement by a participant indicates correct understanding?
A) "I should drink less water to reduce uterine activity"
B) "Menstrual-like cramps are normal and not concerning"
C) "Low, dull backache that comes and goes could be preterm labor"
D) "If I feel fetal movement increase, I should go to the hospital"
Rationale: Persistent low backache, menstrual-like cramps, pelvic pressure, and
change in vaginal discharge are subtle signs of preterm labor. Hydration helps
reduce contractions, so decreasing fluids is harmful. Increased fetal movement is
not a sign of preterm labor.
, 6. A client with preeclampsia is receiving IV magnesium sulfate. Which assessment
finding indicates magnesium toxicity?
A) Deep tendon reflexes 2+
B) Urine output 35 mL/hour
C) Respiratory rate of 10 breaths/minute
D) Blood pressure 140/90 mm Hg
*Rationale: Magnesium sulfate toxicity depresses the CNS, causing decreased respiratory
rate (<12/min), absent DTRs, and decreased urine output (<30 mL/hr). Respiratory
depression is a critical sign requiring immediate intervention with calcium gluconate.*
7. The nurse is caring for a G2P1 client in active labor. The client suddenly reports
severe abdominal pain and a "tearing" sensation. The nurse notes a rigid, board-
like abdomen and non-reassuring fetal heart rate. The nurse suspects:
A) Placenta previa
B) Uterine rupture
C) Abruptio placentae
D) Amniotic fluid embolism
Rationale: Uterine rupture presents with sudden tearing abdominal pain, rigid
abdomen, cessation of contractions, and non-reassuring FHR. Abruptio placentae
causes dark bleeding and uterine tenderness but not typically a "tearing"
sensation. Placenta previa causes painless bleeding.
8. A newborn's Apgar scores are 6 at 1 minute and 8 at 5 minutes. The nurse
understands this indicates:
A) Severe distress requiring NICU admission
B) Moderate difficulty that is improving
C) Normal transition with no intervention needed
D) A need for resuscitation to continue
*Rationale: Apgar scores: 7-10 normal, 4-6 moderately depressed (moderate difficulty),
0-3 severely depressed. The improvement from 6 to 8 shows the newborn is responding
to initial interventions (stimulation, airway clearing).*
9. Which medication is the first-line treatment for postpartum hemorrhage due to
uterine atony?
A) Methylergonovine (Methergine)
B) Oxytocin (Pitocin)
C) Carboprost (Hemabate)
(F.A Davis , 2026) by Luanne Linnard Palmer,
, INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING
1. A nurse is caring for a client in the active phase of labor. Which finding would
require immediate intervention?
A) Cervical dilation from 4 to 6 cm over 4 hours
B) Contractions every 3 minutes lasting 60 seconds
C) Fetal heart rate baseline of 150 bpm with moderate variability
D) Fetal heart rate decelerations that are late and recurrent
Rationale: Late decelerations indicate uteroplacental insufficiency and require
immediate intervention to improve placental blood flow and fetal oxygenation.
Options A and B are normal active phase findings; option C is a normal fetal heart
rate pattern.
2. A primigravida at 39 weeks gestation is admitted with contractions every 5
minutes. Her cervix is 3 cm dilated, 50% effaced, and the fetal head is at -1 station.
The nurse documents this as:
A) Latent phase of labor
B) Active phase of labor
C) Transition phase of labor
D) Early deceleration phase
*Rationale: The latent phase is 0-3 cm, active phase is 4-7 cm, and transition is 8-10 cm.
At 3 cm with regular contractions, the client is at the end of latent/beginning of active
phase, but standard documentation places 3 cm in latent. CORRECTION: Actually, 3 cm
is the end of latent phase (0-3 cm). The correct answer should be latent phase. However,
many texts consider 3 cm as transition to active. To align with safe nursing care,
recognize that active phase begins at 4-6 cm. Thus at 3 cm, the client is in latent phase.*
(Note: I'll correct the above for accuracy)
Corrected Q2: A primigravida at 39 weeks gestation is admitted with contractions
every 5 minutes. Her cervix is 3 cm dilated, 50% effaced, and the fetal head is at -1
station. The nurse documents this as:
A) Latent phase of labor
B) Active phase of labor
C) Transition phase of labor
D) Second stage of labor
, *Rationale: The latent (early) phase of labor is characterized by cervical dilation from 0-3
cm. The active phase begins at 4 cm, transition at 8-10 cm, and second stage is
complete dilation (10 cm) with pushing.*
3. A postpartum client reports a firm, midline fundus but heavy lochia with large
clots. The nurse's priority action is to:
A) Encourage ambulation to promote drainage
B) Administer prescribed oxytocin
C) Assess for bladder distention
D) Perform fundal massage continuously
Rationale: A firm fundus with heavy bleeding and clots suggests retained products
or bladder distention displacing the uterus. Bladder distention prevents uterine
contraction. The nurse should first assess for bladder distention and have the client
void before other interventions.
4. Which finding in a newborn at 4 hours of life requires immediate notification of
the healthcare provider?
A) Acrocyanosis of hands and feet
B) Respiratory rate of 60 breaths per minute
C) Apical heart rate of 160 bpm while crying
D) Grunting with nasal flaring
*Rationale: Grunting, nasal flaring, and retractions are signs of respiratory distress in a
newborn. Acrocyanosis is normal in the first 24 hours. A respiratory rate of 60 is normal
(normal range 30-60). Heart rate 160 is within normal limits (110-160, can increase with
crying).*
5. A nurse is teaching a prenatal class about signs of preterm labor. Which
statement by a participant indicates correct understanding?
A) "I should drink less water to reduce uterine activity"
B) "Menstrual-like cramps are normal and not concerning"
C) "Low, dull backache that comes and goes could be preterm labor"
D) "If I feel fetal movement increase, I should go to the hospital"
Rationale: Persistent low backache, menstrual-like cramps, pelvic pressure, and
change in vaginal discharge are subtle signs of preterm labor. Hydration helps
reduce contractions, so decreasing fluids is harmful. Increased fetal movement is
not a sign of preterm labor.
, 6. A client with preeclampsia is receiving IV magnesium sulfate. Which assessment
finding indicates magnesium toxicity?
A) Deep tendon reflexes 2+
B) Urine output 35 mL/hour
C) Respiratory rate of 10 breaths/minute
D) Blood pressure 140/90 mm Hg
*Rationale: Magnesium sulfate toxicity depresses the CNS, causing decreased respiratory
rate (<12/min), absent DTRs, and decreased urine output (<30 mL/hr). Respiratory
depression is a critical sign requiring immediate intervention with calcium gluconate.*
7. The nurse is caring for a G2P1 client in active labor. The client suddenly reports
severe abdominal pain and a "tearing" sensation. The nurse notes a rigid, board-
like abdomen and non-reassuring fetal heart rate. The nurse suspects:
A) Placenta previa
B) Uterine rupture
C) Abruptio placentae
D) Amniotic fluid embolism
Rationale: Uterine rupture presents with sudden tearing abdominal pain, rigid
abdomen, cessation of contractions, and non-reassuring FHR. Abruptio placentae
causes dark bleeding and uterine tenderness but not typically a "tearing"
sensation. Placenta previa causes painless bleeding.
8. A newborn's Apgar scores are 6 at 1 minute and 8 at 5 minutes. The nurse
understands this indicates:
A) Severe distress requiring NICU admission
B) Moderate difficulty that is improving
C) Normal transition with no intervention needed
D) A need for resuscitation to continue
*Rationale: Apgar scores: 7-10 normal, 4-6 moderately depressed (moderate difficulty),
0-3 severely depressed. The improvement from 6 to 8 shows the newborn is responding
to initial interventions (stimulation, airway clearing).*
9. Which medication is the first-line treatment for postpartum hemorrhage due to
uterine atony?
A) Methylergonovine (Methergine)
B) Oxytocin (Pitocin)
C) Carboprost (Hemabate)
