Healthcare and Nursing Maternal & Newborn Nursing 1 — Questions and Answers
Question 1: The APGAR score is assessed at what time intervals after birth?
- 1 and 5 minutes (Correct answer)
- 2 and 10 minutes
- 5 and 10 minutes
- 1 and 10 minutes
Correct answer: 1 and 5 minutes
APGAR scores are routinely assessed at 1 minute and 5 minutes after birth to evaluate the newborn's adaptation to extrauterine life.
Question 2: What is the normal fetal heart rate range during labor?
- 80–100 bpm
- 110–160 bpm (Correct answer)
- 160–180 bpm
- 100–110 bpm
Correct answer: 110–160 bpm
A normal fetal heart rate is 110–160 bpm; rates outside this range may indicate fetal distress requiring further assessment.
Question 3: Which finding best distinguishes true labor from Braxton Hicks contractions?
- Contractions that stop with ambulation
- Irregular contractions with no cervical change
- Regular contractions that increase in intensity with progressive cervical dilation (Correct answer)
- Contractions confined to the lower abdomen only
Correct answer: Regular contractions that increase in intensity with progressive cervical dilation
True labor is characterized by regular contractions that intensify over time and produce measurable cervical dilation, effacement, and fetal descent.
Question 4: At 20 weeks gestation, where should the nurse expect the fundus to be located?
- At the symphysis pubis
- At the level of the umbilicus (Correct answer)
- Halfway between the umbilicus and xiphoid process
- Just above the symphysis pubis
Correct answer: At the level of the umbilicus
At 20 weeks, the fundus is typically at the umbilicus; fundal height in centimeters approximates gestational age in weeks from about 20–36 weeks.
Question 5: Which component of the APGAR score evaluates muscle tone in the newborn?
- Appearance
- Pulse
- Activity (Correct answer)
- Respiration
Correct answer: Activity
Activity in the APGAR acronym refers to muscle tone, scored 0 (limp), 1 (some flexion), or 2 (active motion with well-flexed extremities).
Question 6: Which finding in a pregnant patient at 36 weeks requires the most immediate nursing action?
- Mild ankle edema bilaterally
- Blood pressure of 162/112 mmHg with headache and visual changes (Correct answer)
- Weight gain of 1 lb per week over the past month
- Fetal movement of 10 kicks in 2 hours
Correct answer: Blood pressure of 162/112 mmHg with headache and visual changes
Severe-range blood pressure (≥160/110) with headache and visual changes indicates severe preeclampsia, a medical emergency requiring immediate intervention.
Question 7: A nurse is caring for a primigravida in the second stage of labor. Which nursing intervention is the priority?
- Encourage pushing with every urge to bear down during contractions (Correct answer)
- Restrict oral fluids to prevent aspiration
- Position the patient supine for continuous electronic fetal monitoring
- Perform amniotomy to accelerate delivery
Correct answer: Encourage pushing with every urge to bear down during contractions
During the second stage of labor, guiding the patient to push effectively with contractions facilitates fetal descent and delivery.
