Maternal and Newborn Nursing – RN Practice Questions

These 15 items are written at NCLEX-RN level, emphasizing recognition of obstetric emergencies, clinical judgment, and prioritization. Options are numbered; the answer key gives the number and the corresponding letter (1 = A, 2 = B, and so on). Core content for this subject is at Maternal and Newborn Nursing.

Question 1

A nurse performs a vaginal examination immediately after spontaneous rupture of membranes in a client at 39 weeks' gestation and palpates a pulsating cord in the vagina. The fetal heart rate drops to 70 beats per minute. Which action should the nurse take first?

1. Administer oxygen at 10 L/min by nonrebreather mask.
2. Keep the gloved hand in the vagina and lift the presenting part off the cord.
3. Place the client in a knee-chest position.
4. Gently replace the cord into the uterus with sterile gauze.

Answer: 2 (B). Keep the gloved hand in the vagina and lift the presenting part off the cord.

Rationale: Umbilical cord prolapse is an immediate threat to fetal oxygenation caused by compression of the cord between the presenting part and the pelvis. Because the nurse's hand is already in place, manually elevating the presenting part relieves compression instantly and is the fastest available action. The hand stays there until cesarean delivery. Option 1 (oxygen) and option 3 (knee-chest or steep Trendelenburg positioning) are both correct interventions but follow relief of the direct compression, and positioning takes longer to accomplish. Option 4 is never done; replacing the cord can cause vasospasm and further compression, and it delays definitive care.

Question 2

A client with preeclampsia with severe features is receiving IV magnesium sulfate. Assessment reveals a respiratory rate of 10 breaths per minute, absent deep tendon reflexes, and a urine output of 20 mL over the past hour. Which action should the nurse take first?

1. Notify the health care provider.
2. Administer calcium gluconate IV.
3. Stop the magnesium sulfate infusion.
4. Obtain a serum magnesium level.

Answer: 3 (C). Stop the magnesium sulfate infusion.

Rationale: This client has magnesium toxicity. The first action is to stop the drug that is causing the harm, which halts further accumulation immediately and can be done in seconds. Calcium gluconate (option 2) is the antidote and is given next, but administering it while the infusion continues is illogical. Notifying the provider (option 1) and drawing a level (option 4) are both appropriate but do not stop the ongoing injury. Note the progression of toxicity: loss of deep tendon reflexes appears first, then respiratory depression, then decreased level of consciousness and cardiac arrest. Oliguria worsens toxicity because magnesium is cleared by the kidneys.

Question 3

A nurse is evaluating a client at 34 weeks' gestation with gestational hypertension. Which findings indicate progression to preeclampsia with severe features? Select all that apply.

1. Blood pressure 164/112 mm Hg on two readings 6 hours apart
2. Platelet count 68,000/mm3
3. Trace proteinuria on dipstick
4. New-onset headache unrelieved by acetaminophen with blurred vision
5. Serum aspartate aminotransferase (AST) three times the upper limit of normal
6. Dependent ankle edema after standing all day

Answer: 1, 2, 4, 5 (A, B, D, E).

Rationale: Severe features include systolic pressure of 160 mm Hg or higher or diastolic of 110 mm Hg or higher on two occasions, thrombocytopenia below 100,000/mm3, new cerebral or visual disturbance, impaired liver function or severe persistent right upper quadrant pain, renal insufficiency, and pulmonary edema. Option 3 is wrong because the degree of proteinuria is not used to define severe disease; a client can have severe preeclampsia with little or no protein. Option 6 is wrong because dependent lower extremity edema is a common normal finding in late pregnancy; sudden facial and hand edema is the concerning pattern, and even that is not a diagnostic criterion.

Question 4

Two hours after a vaginal birth, a client has saturated a perineal pad with bright red blood in 20 minutes. The nurse palpates a firm fundus at the level of the umbilicus, midline. Which action is the priority?

1. Massage the fundus vigorously.
2. Administer methylergonovine as ordered.
3. Inspect the perineum and vagina and notify the provider.
4. Assist the client to empty her bladder.

Answer: 3 (C). Inspect the perineum and vagina and notify the provider.

Rationale: Heavy bright red bleeding in the presence of a firm, midline fundus points away from uterine atony and toward a genital tract laceration or hematoma, which requires visualization and surgical repair. Massaging an already firm uterus (option 1) accomplishes nothing and causes pain and possible uterine relaxation from overstimulation. Uterotonics (option 2) treat atony, which is not the problem here, and methylergonovine also carries a blood pressure contraindication that has not been assessed. Emptying the bladder (option 4) is indicated when the fundus is high and deviated, which is not described.

Question 5

A nurse reviewing a fetal monitor tracing observes a baseline of 145 beats per minute with minimal variability and repetitive decelerations that begin after the peak of each contraction and return to baseline after the contraction ends. Oxytocin is infusing at 8 milliunits per minute. Which action should the nurse take first?

1. Discontinue the oxytocin infusion.
2. Increase the IV maintenance fluid rate.
3. Apply oxygen at 10 L/min by nonrebreather mask.
4. Prepare the client for immediate cesarean birth.

Answer: 1 (A). Discontinue the oxytocin infusion.

Rationale: Recurrent late decelerations with minimal variability indicate uteroplacental insufficiency. Contractions reduce placental perfusion, so removing the stimulus that is causing them is the first and most effective step, and stopping oxytocin is an independent nursing action that does not require an order. Fluid bolus (option 2) and oxygen (option 3) are also part of intrauterine resuscitation, along with lateral repositioning, but they follow removal of the cause. Option 4 may become necessary if the pattern does not resolve, but it is not the nurse's first action and requires provider evaluation.

Question 6

A postpartum client with a boggy uterus and continued bleeding has received oxytocin without adequate response. The provider orders methylergonovine 0.2 mg IM. Which assessment finding requires the nurse to hold the medication and contact the provider?

1. Blood pressure 158/98 mm Hg
2. Pulse 104 beats per minute
3. History of asthma
4. Report of severe afterpains

Answer: 1 (A). Blood pressure 158/98 mm Hg.

Rationale: Methylergonovine is an ergot alkaloid that causes generalized vasoconstriction and can precipitate a dangerous rise in blood pressure, seizure, or stroke. It is contraindicated in hypertension and preeclampsia, so the blood pressure is checked before every dose. Tachycardia (option 2) is an expected sign of blood loss and reinforces the need for a uterotonic. Asthma (option 3) is the contraindication for carboprost, not methylergonovine, and is a classic distractor pairing. Afterpains (option 4) are expected with uterine contraction and are treated with analgesia, not by withholding the drug.

Question 7

During a vaginal birth the fetal head delivers and then retracts tightly against the perineum, and the shoulders do not deliver with the next contraction. Which nursing action is appropriate?

1. Apply firm fundal pressure to dislodge the shoulder.
2. Sharply flex the client's thighs onto her abdomen and apply suprapubic pressure.
3. Instruct the client to push harder and more continuously.
4. Place the client in a high Fowler position.

Answer: 2 (B). Sharply flex the client's thighs onto her abdomen and apply suprapubic pressure.

Rationale: This is shoulder dystocia with the turtle sign. The McRoberts maneuver flattens the sacral promontory and rotates the symphysis pubis, and suprapubic pressure adducts the fetal shoulder to free it from behind the symphysis. Fundal pressure (option 1) is contraindicated because it drives the shoulder harder into the symphysis and risks uterine rupture and worse fetal injury. Option 3 alone does not resolve mechanical impaction. Option 4 does not change the pelvic geometry in a useful way. Anticipate postpartum hemorrhage and assess the newborn for brachial plexus injury and clavicle fracture.

Question 8

A client at 32 weeks' gestation with chronic hypertension reports sudden constant abdominal pain. Which findings support a diagnosis of placental abruption? Select all that apply.

1. A rigid, board-like, tender uterus
2. Painless bright red vaginal bleeding
3. Dark red vaginal bleeding, possibly minimal relative to symptoms
4. Category III fetal heart rate tracing
5. A fundal height that increases over serial measurements
6. A soft, nontender, relaxed uterus between contractions

Answer: 1, 3, 4, 5 (A, C, D, E).

Rationale: Abruption is premature separation of a normally implanted placenta. Blood dissects into the myometrium, producing a rigid, exquisitely tender uterus, dark bleeding, and often a nonreassuring or Category III tracing from loss of placental surface area. Bleeding can be concealed behind the placenta, so an enlarging uterus or rising fundal height signals ongoing blood loss even when external bleeding looks trivial; never estimate abruption severity from visible blood alone. Options 2 and 6 describe placenta previa, in which bleeding is painless and bright red and the uterus stays soft. Watch for DIC and hypovolemic shock, and remember that no vaginal examination is performed when previa has not been ruled out.

Question 9

A charge nurse on a labor and delivery unit receives report on four clients. Which client should the nurse assess first?

1. A client at 39 weeks in active labor reporting an urge to push
2. A client 1 hour postpartum with a fundus 2 cm above the umbilicus and deviated to the right
3. A client at 30 weeks receiving magnesium sulfate who reports feeling flushed and warm
4. A client at 36 weeks with preeclampsia reporting new right upper quadrant pain and nausea

Answer: 4 (D). The client at 36 weeks with preeclampsia reporting new right upper quadrant pain and nausea.

Rationale: New epigastric or right upper quadrant pain in preeclampsia reflects hepatic capsular distention and suggests HELLP syndrome or impending eclampsia, an unstable and rapidly deteriorating picture. Option 1 is urgent and needs prompt evaluation, but an urge to push in active labor is an expected progression of a physiologic process. Option 2 is a classic full bladder, which is common, easily corrected, and delegable to an assessment that can follow within minutes. Option 3 describes expected effects of magnesium (flushing, warmth, sedation), not toxicity; toxicity would be loss of deep tendon reflexes or respiratory depression. Apply the rule that the unexpected, unstable, and deteriorating client outranks the expected and the correctable.

Question 10

A nurse is caring for a 1-hour-old newborn weighing 4,200 g born to a mother with gestational diabetes. The infant is jittery, has a weak cry, and feels cool. Which action should the nurse take first?

1. Obtain a bedside blood glucose level.
2. Place the infant skin to skin with the mother.
3. Notify the neonatal provider.
4. Swaddle the infant and recheck in 30 minutes.

Answer: 1 (A). Obtain a bedside blood glucose level.

Rationale: A large-for-gestational-age infant of a diabetic mother has been exposed to maternal hyperglycemia in utero, has developed hyperinsulinemia, and loses the maternal glucose supply abruptly at birth, making hypoglycemia highly likely. Jitteriness, weak cry, and temperature instability are classic nonspecific signs. Assessment precedes intervention when the finding is easily and quickly measurable and will determine treatment. Skin-to-skin contact (option 2) is valuable and will follow, and early feeding is the usual treatment for an asymptomatic infant, but a symptomatic infant needs a value first. Option 3 is premature without data. Option 4 delays recognition of a condition that can cause seizures and neurologic injury.

Question 11

A client at 37 weeks' gestation with preeclampsia begins to have a generalized tonic-clonic seizure. Which nursing action is the priority?

1. Insert a padded tongue blade to protect the airway.
2. Turn the client to her side and ensure suction and oxygen are available.
3. Prepare for immediate cesarean birth.
4. Administer a magnesium sulfate bolus.

Answer: 2 (B). Turn the client to her side and ensure suction and oxygen are available.

Rationale: During an eclamptic seizure the priority is maternal airway protection and preventing aspiration and injury; side-lying positioning uses gravity to keep secretions out of the airway and also improves uteroplacental perfusion by relieving vena cava compression. Nothing is ever inserted into the mouth of a seizing patient (option 1), which can cause dental, oral, and airway injury. Option 4 is the correct pharmacologic treatment and follows once the client is protected. Option 3 is premature; the client is stabilized first, because delivering an unstable, hypoxic, acidotic mother worsens outcomes for both patients.

Question 12

A nurse is preparing to administer carboprost tromethamine to a postpartum client with refractory uterine atony. Which item in the client's history most requires the nurse to question the order?

1. Type 2 diabetes mellitus
2. Asthma requiring daily inhaled corticosteroids
3. Iron deficiency anemia
4. Prior cesarean birth

Answer: 2 (B). Asthma requiring daily inhaled corticosteroids.

Rationale: Carboprost is a prostaglandin F2-alpha analogue that causes bronchoconstriction and is contraindicated in asthma because it can precipitate severe bronchospasm. Expected adverse effects in any client include diarrhea, nausea, vomiting, fever, and chills, and antidiarrheal premedication is often given. Diabetes (option 1) and anemia (option 3) are not contraindications, and anemia in fact increases the urgency of controlling bleeding. Prior cesarean birth (option 4) raises the risk of atony and abnormal placentation but is not a contraindication to the drug.

Question 13

A nurse assesses a 12-hour-old newborn and finds a firm, unilateral swelling over the right parietal bone that does not cross the sagittal suture and was not present at birth. Which nursing action is most appropriate?

1. Document the caput succedaneum and reassure the parents it will resolve in a few days.
2. Monitor the infant for hyperbilirubinemia and report the finding to the provider.
3. Apply gentle pressure to the area to reduce the swelling.
4. Prepare the infant for immediate cranial imaging.

Answer: 2 (B). Monitor the infant for hyperbilirubinemia and report the finding to the provider.

Rationale: Swelling that does not cross suture lines and appears after birth is a cephalhematoma, a subperiosteal collection of blood bounded by the periosteum of a single cranial bone. As the trapped red cells break down they release a bilirubin load that an immature liver may not conjugate fast enough, so these infants need bilirubin surveillance, and resolution takes weeks to months. Option 1 describes caput succedaneum, which is soft scalp edema, is present at birth, does cross suture lines, and resolves in days. Option 3 could cause further bleeding and tissue injury. Option 4 is not routinely indicated for an uncomplicated cephalhematoma in an otherwise well infant.

Question 14

A nurse identifies a Category III fetal heart rate tracing in a client at 38 weeks in active labor. Which interventions should the nurse implement? Select all that apply.

1. Reposition the client to a lateral position
2. Discontinue the oxytocin infusion
3. Administer an IV bolus of lactated Ringer solution
4. Place the client in a supine position to obtain a clearer tracing
5. Notify the provider and prepare for possible expedited birth
6. Perform a vaginal examination to assess for cord prolapse and rapid descent

Answer: 1, 2, 3, 5, 6 (A, B, C, E, F).

Rationale: Category III tracings (absent variability with recurrent late or variable decelerations or bradycardia, or a sinusoidal pattern) are associated with abnormal fetal acid-base status and require prompt intrauterine resuscitation and preparation for delivery. Lateral positioning relieves aortocaval compression and often relieves cord compression, stopping oxytocin restores placental perfusion between contractions, a fluid bolus supports maternal circulating volume and corrects hypotension, a vaginal examination rules out a treatable mechanical cause, and the provider must be notified. Option 4 is wrong and harmful: the supine position compresses the inferior vena cava and further reduces uteroplacental perfusion.

Question 15

A nurse makes a home visit to a client 10 days after birth. The client states she has not slept in three days, believes her infant "has been replaced by a demon," and hears a voice telling her the baby must be protected from her. Which action should the nurse take?

1. Reassure the client that postpartum blues are common and resolve within two weeks.
2. Encourage the client to increase rest and follow up at the six-week postpartum visit.
3. Arrange immediate psychiatric evaluation and ensure the infant is not left alone with the client.
4. Screen the client with the Edinburgh Postnatal Depression Scale and refer for outpatient counseling.

Answer: 3 (C). Arrange immediate psychiatric evaluation and ensure the infant is not left alone with the client.

Rationale: Delusions about the infant, auditory hallucinations, and severe insomnia with rapid onset in the first weeks describe postpartum psychosis, a psychiatric emergency carrying substantial risk of suicide and infanticide. It requires urgent evaluation and usually inpatient treatment, and infant safety must be secured immediately. Option 1 is incorrect because postpartum blues involve tearfulness and mood lability without psychosis. Option 2 dangerously delays care. Option 4 is appropriate screening for postpartum depression, but outpatient referral is not sufficient when psychotic symptoms and a command related to the infant are present.

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