RNC-MNN: Maternal Newborn Nursing Certification Exam — Questions and Answers

Question 1: Which assessment best indicates that postpartum involution is progressing normally on day 3?

Fundus palpable at the umbilicus
Fundus palpable at the symphysis pubis
Fundus not palpable abdominally
Fundus 3 cm below the umbilicus (Correct answer)

Correct answer: Fundus 3 cm below the umbilicus

The uterus descends approximately 1 cm (one fingerbreadth) per day; by day 3 it should be approximately 3 cm below the umbilicus.

Question 2: A postpartum client reports passing a plum-sized clot. After assessing the fundus is firm, what should the nurse do next?

Notify the physician and save the clot for evaluation (Correct answer)
Perform a vaginal exam to check for lacerations
Document as a normal finding and continue monitoring
Administer methylergonovine (Methergine) immediately

Correct answer: Notify the physician and save the clot for evaluation

Clots larger than a quarter (golf-ball or plum-sized) are abnormal and should be reported to the provider and saved for quantification.

Question 3: Six hours postpartum (PP) after delivering a full-term healthy infant, the client is being evaluated by the nurse. The customer complains to the nurse of feeling lightheaded and faint. Which of the following nurse interventions would be ideal?

Obtain hemoglobin and hematocrit levels.
Inform the nursery room nurse to avoid bringing the newborn infant to the mother until the feelings of lightheadedness and dizziness have subsided.
Instruct the mother to request help when getting out of bed. (Correct answer)
Elevate the mother’s legs.

Correct answer: Instruct the mother to request help when getting out of bed.

During the first eight hours following birth, orthostatic hypotension may be visible. Feelings of dizziness or faintness are indicators that the client's safety should be taken into consideration by the nurse. The first few times the mother gets out of bed, the nurse should suggest that she seek assistance.

Question 4: A patient with preeclampsia is receiving magnesium sulfate. Which assessment finding indicates magnesium toxicity?

Deep tendon reflexes 2+
Serum magnesium level of 5 mEq/L
Urine output of 40 mL/hr
Respiratory rate of 10 breaths per minute (Correct answer)

Correct answer: Respiratory rate of 10 breaths per minute

Respiratory depression (rate <12) is a key sign of magnesium toxicity; the antidote calcium gluconate should be administered immediately to reverse the toxicity.

Question 5: Which of the following medications would the nurse anticipate giving to the postpartum patient while they are on heparin for thrombophlebitis if they experience difficulties from the medication?

Methylergonovine (Methergine)
Calcium gluconate
Nitrofurantoin (Macrodantin)
Protamine sulfate (Correct answer)

Correct answer: Protamine sulfate

Heparin antagonist protamine sulfate is administered intravenously to prevent bleeding issues brought on by heparin overload.

Question 6: A nurse is performing the Edinburgh Postnatal Depression Scale (EPDS) screening. At what score should the nurse initiate immediate follow-up?

Any score above zero
Score of 13 or higher (Correct answer)
Score of 5 or higher
Score of 10 or higher

Correct answer: Score of 13 or higher

An EPDS score of 13 or higher indicates probable postpartum depression and requires immediate referral and further mental health evaluation.

Question 7: A patient in active labor requests pain relief. She is 7 cm dilated. Which analgesic option is CONTRAINDICATED this close to delivery due to risk of neonatal respiratory depression?

Intrathecal opioids via spinal block
Epidural analgesia
IV morphine sulfate (Correct answer)
Nitrous oxide

Correct answer: IV morphine sulfate

IV systemic opioids such as morphine cross the placenta and can cause neonatal respiratory depression if given too close to delivery, especially at 7 cm.

Question 8: A nurse is performing a gestational age assessment using the Ballard score on a newborn. Which physical finding suggests a gestational age of approximately 40 weeks?

Plantar creases covering the entire sole (Correct answer)
Ear cartilage that is soft with slow recoil
Abundant lanugo covering the entire body
Transparent, gelatinous skin with visible veins

Correct answer: Plantar creases covering the entire sole

Full-term newborns (40 weeks) have plantar creases extending across the entire sole of the foot, reflecting mature skin development.

Question 9: Which assessment finding in a male newborn requires notification of the provider?

Smegma beneath the foreskin
Testes palpable in the inguinal canal
Rugae on the scrotum
Undescended testicle (cryptorchidism) (Correct answer)

Correct answer: Undescended testicle (cryptorchidism)

Cryptorchidism requires provider notification and follow-up as undescended testes that do not descend by 6 months require surgical intervention (orchiopexy) to prevent infertility and malignancy.

Question 10: Which assessment finding would indicate a client in labor is experiencing hypotonic uterine dysfunction?

Contractions less than 25 mmHg in intensity with a frequency of more than every 5 minutes (Correct answer)
Cervical dilation of less than 1.2 cm per hour in the active phase
Failure of the presenting part to descend despite adequate contractions
Contractions occurring every 2 minutes with a duration of 90 seconds

Correct answer: Contractions less than 25 mmHg in intensity with a frequency of more than every 5 minutes

Hypotonic uterine dysfunction is characterized by weak, ineffective contractions (<25 mmHg intensity) that are infrequent, which fail to dilate the cervix adequately.

Question 11: A mother asks about introducing cow's milk to her 10-month-old breastfed infant. What is the nurse's best response?

Whole cow's milk can be introduced at 6 months
Whole cow's milk should not be introduced as the primary drink until 12 months of age (Correct answer)
Skim or low-fat milk is preferred from 9 months
Cow's milk is safe to start anytime after 6 months as a supplement

Correct answer: Whole cow's milk should not be introduced as the primary drink until 12 months of age

Whole cow's milk is not recommended as the primary beverage before 12 months because it lacks sufficient iron, has too much protein and sodium for immature kidneys, and may cause occult GI blood loss.

Question 12: A client with gestational diabetes is being taught about diet management. Which meal plan choice is MOST appropriate?

Eliminate all carbohydrates from the diet
Distribute carbohydrates evenly across three meals and two to three snacks (Correct answer)
Consume three large meals daily with no snacks
Eat a high-carbohydrate diet to meet fetal glucose needs

Correct answer: Distribute carbohydrates evenly across three meals and two to three snacks

Distributing carbohydrates evenly helps maintain stable blood glucose levels and prevents postprandial hyperglycemia.

Question 13: Which of the following would the charge nurse anticipate doing when taking care of a 3-day-old neonate who is receiving phototherapy to treat jaundice?

Encourage the mother to discontinue breastfeeding
Check the vital signs every 2 to 4 hours. (Correct answer)
Notify the physician if the skin becomes bronze in color.
Turn the neonate every 6 hours

Correct answer: Check the vital signs every 2 to 4 hours.

Vital signs should be monitored every 2 to 4 hours when caring for an infant who is receiving phototherapy for the treatment of jaundice since the phototherapy lamps can cause overheating.

Question 14: At 1 minute of life, a newborn has a heart rate of 98 bpm, slow irregular respirations, some flexion of extremities, a grimace in response to stimulation, and a pink body with blue extremities. What is the Apgar score?

8
7
6 (Correct answer)
5

Correct answer: 6

Heart rate <100=1, slow respirations=1, some flexion=1, grimace=1, acrocyanosis=1 — totaling an Apgar score of 6.

Question 15: Which finding on newborn skin assessment is a normal variation that does NOT require intervention?

Pustular rash spreading rapidly
Pallor with mottling persisting beyond 2 hours
Erythema toxicum (Correct answer)
Port-wine stain over the face

Correct answer: Erythema toxicum

Erythema toxicum neonatorum is a benign, self-limiting rash of unknown cause appearing in 30–70% of full-term newborns and requires no treatment.

Question 16: A laboring client at 8 cm dilation reports uncontrollable urge to push. Which nursing intervention is most appropriate at this time?

Encourage the client to push with each contraction
Instruct the client to use panting or blowing breathing to resist the urge to push (Correct answer)
Place the client in the lithotomy position and prepare for delivery
Administer IV morphine to decrease the sensation

Correct answer: Instruct the client to use panting or blowing breathing to resist the urge to push

Until the cervix is fully dilated (10 cm), pushing is discouraged; panting or blowing techniques help the client resist the urge and prevent cervical edema.

Question 17: A patient is 3 hours postpartum and her uterus is displaced to the right of the umbilicus and feels boggy. What is the likely cause and appropriate intervention?

Uterine rupture; prepare for emergency surgery
Uterine atony from a distended bladder; assist the patient to void (Correct answer)
Postpartum hemorrhage; administer oxytocin IV
Normal uterine involution; reassess in 1 hour

Correct answer: Uterine atony from a distended bladder; assist the patient to void

A laterally displaced boggy uterus postpartum is a classic sign of bladder distension displacing the uterus; voiding allows the uterus to contract properly to the midline.

Question 18: When performing umbilical cord care, what should the nurse teach parents?

Keep the cord dry, fold diapers below the cord, and allow it to dry and fall off naturally in 7–14 days (Correct answer)
Cover the cord with petroleum jelly to prevent drying
Clean the cord with alcohol swabs with each diaper change
Bandage the cord stump to protect it from air exposure

Correct answer: Keep the cord dry, fold diapers below the cord, and allow it to dry and fall off naturally in 7–14 days

Current evidence supports dry cord care (keeping the cord clean and dry without antiseptic); the diaper should be folded below the cord to prevent urine contamination, and the cord naturally separates in 7–14 days.

Question 19: Which newborn screening test, performed before hospital discharge, detects critical congenital heart defects (CCHD)?

12-lead electrocardiogram
Chest X-ray
Pulse oximetry screening on the right hand and either foot (Correct answer)
Echocardiogram

Correct answer: Pulse oximetry screening on the right hand and either foot

CCHD screening uses pulse oximetry on the right hand (preductal) and one foot (postductal); a difference >3% or reading <95% warrants further evaluation.

Question 20: A nurse is preparing to administer erythromycin ophthalmic ointment to a newborn. What is the purpose of this medication?

To prevent vitamin A deficiency and improve vision
To reduce intraocular pressure in the newborn
To treat congenital cataracts
To provide prophylaxis against ophthalmia neonatorum from gonorrhea and Chlamydia (Correct answer)

Correct answer: To provide prophylaxis against ophthalmia neonatorum from gonorrhea and Chlamydia

Erythromycin 0.5% ophthalmic ointment is administered to all newborns to prevent ophthalmia neonatorum, a serious eye infection that can cause blindness if caused by Neisseria gonorrhoeae.

Question 21: Which position should the nurse teach a client with a third-degree perineal laceration to use for most comfortable sitting?

Sitting upright on a hard surface
Sitting with legs crossed to protect the perineum
Lying flat to avoid any pressure
Clenching buttocks together before sitting and using a foam donut cushion (Correct answer)

Correct answer: Clenching buttocks together before sitting and using a foam donut cushion

Squeezing the buttocks together before sitting reduces direct pressure on the perineum, and a foam ring cushion further relieves discomfort.

Question 22: A nurse is preparing to administer oxytocin (Pitocin) for labor augmentation. Which assessment finding requires withholding the medication and notifying the provider?

Cervical dilation of 4 cm
Uterine contractions occurring every 2 minutes lasting 90 seconds (Correct answer)
Fetal heart rate baseline of 140 bpm with moderate variability
Intact amniotic membranes

Correct answer: Uterine contractions occurring every 2 minutes lasting 90 seconds

Contractions lasting >90 seconds or occurring more frequently than every 2 minutes (uterine tachysystole) are a contraindication to oxytocin administration and require provider notification.

Question 23: A postpartum client is Rh-negative and delivered an Rh-positive infant. When should Rho(D) immune globulin (RhoGAM) be administered?

Within 12 hours of delivery
Within 72 hours of delivery (Correct answer)
At the 6-week postpartum visit
Only if the Coombs test is positive

Correct answer: Within 72 hours of delivery

RhoGAM must be given within 72 hours of delivery to prevent maternal sensitization against Rh-positive fetal red blood cells.

Question 24: A woman who just gave birth to a healthy newborn baby four hours ago is having her vital signs taken by a postpartum nurse. The mother's temperature is 100.2°F, the nurse reports. Which of the following would be the best course of action?

Retake the temperature in 15 minutes.
Increase hydration by encouraging oral fluids (Correct answer)
Notify the physician
Document the findings.

Correct answer: Increase hydration by encouraging oral fluids

While the mother is awake, her temperature can be taken every four hours. In the first 24 hours following delivery, temperatures as high as 100.4 F (38 C) are frequently attributed to the dehydrating effects of labor. The best course of action is to encourage oral fluid intake in order to enhance hydration, which should return the temperature to normal.

Question 25: Which nonpharmacological intervention has the strongest evidence for treating mild-to-moderate postpartum depression?

Cognitive-behavioral therapy (CBT) (Correct answer)
Yoga and meditation only
Dietary supplementation with omega-3 fatty acids
Increased caffeine intake to reduce fatigue

Correct answer: Cognitive-behavioral therapy (CBT)

Cognitive-behavioral therapy (CBT) has the most robust evidence base among nonpharmacological treatments for mild to moderate postpartum depression.

Question 26: A client at 28 weeks gestation is undergoing a biophysical profile (BPP). Which score indicates fetal well-being and no need for immediate intervention?

Score of 2 out of 10
Score of 4 out of 10
Score of 6 out of 10
Score of 8 out of 10 (Correct answer)

Correct answer: Score of 8 out of 10

A BPP score of 8–10 out of 10 is considered normal and reassuring, indicating no fetal asphyxia.

Question 27: A nurse is preparing a newborn for phototherapy to treat hyperbilirubinemia. Which nursing intervention is essential?

Cover the eyes with opaque eye patches and expose maximum skin surface to the light (Correct answer)
Feed the newborn less frequently to reduce bilirubin load
Keep the newborn bundled in a blanket during therapy
Apply sunscreen to protect from UV light exposure

Correct answer: Cover the eyes with opaque eye patches and expose maximum skin surface to the light

Phototherapy works by converting bilirubin in the skin to a water-soluble form for excretion; eye patches protect against retinal damage, and maximum skin exposure increases effectiveness.

Question 28: A 30-week preterm infant develops abdominal distension, blood in the stool, and feeding intolerance. Which condition should the nurse suspect?

Necrotizing enterocolitis (NEC) (Correct answer)
Hirschsprung disease
Intussusception
Pyloric stenosis

Correct answer: Necrotizing enterocolitis (NEC)

Necrotizing enterocolitis is an acute intestinal inflammatory emergency in preterm infants presenting with abdominal distension, bloody stools, and feeding intolerance.

Question 29: During the second stage of labor, the nurse identifies variable decelerations with each push. What intervention should the nurse implement first?

Perform an amnioinfusion
Have the patient stop pushing and change position (Correct answer)
Apply oxygen via face mask at 10 L/min
Increase the oxytocin infusion rate

Correct answer: Have the patient stop pushing and change position

Variable decelerations are caused by umbilical cord compression, and repositioning the patient can relieve cord pressure and resolve the pattern.

Question 30: The nurse is performing a newborn assessment at 2 hours of life. Which finding requires immediate notification of the healthcare provider?

Respiratory rate of 52 breaths per minute
Milia on the nose and cheeks
Lanugo on the shoulders and back
Nasal flaring and expiratory grunting (Correct answer)

Correct answer: Nasal flaring and expiratory grunting

Nasal flaring and expiratory grunting are signs of respiratory distress in the newborn and require prompt medical evaluation.

Question 31: A client is prescribed methylergonovine (Methergine) for postpartum uterine atony. Which vital sign is a contraindication to administering this medication?

Temperature of 37.8°C (100°F)
Heart rate of 58 bpm
Blood pressure of 148/94 mmHg (Correct answer)
Respiratory rate of 18 breaths/min

Correct answer: Blood pressure of 148/94 mmHg

Methylergonovine is a vasoconstrictor and is contraindicated in hypertension because it can dangerously elevate blood pressure.

Question 32: A patient in active labor has an epidural. Her blood pressure drops to 88/52 mmHg. What is the nurse's priority intervention?

Position the patient in left lateral tilt and increase IV fluids (Correct answer)
Document the finding and recheck in 5 minutes
Call the anesthesiologist immediately
Administer oxygen by non-rebreather mask

Correct answer: Position the patient in left lateral tilt and increase IV fluids

Epidural-induced hypotension is treated first with left lateral positioning to relieve aortocaval compression and IV fluid bolus to restore maternal blood pressure.

Question 33: A patient develops disseminated intravascular coagulation (DIC) following placental abruption. Which laboratory result is consistent with DIC?

Decreased fibrinogen, prolonged PT and aPTT, elevated D-dimer (Correct answer)
Elevated platelets, normal clotting times
Decreased D-dimer, elevated hemoglobin
Elevated fibrinogen, decreased PT, decreased aPTT

Correct answer: Decreased fibrinogen, prolonged PT and aPTT, elevated D-dimer

DIC causes simultaneous clotting and bleeding, consuming clotting factors and platelets, resulting in low fibrinogen, prolonged PT/aPTT, elevated D-dimer, and thrombocytopenia.

Question 34: A patient at 36 weeks has been diagnosed with obstetric cholestasis (intrahepatic cholestasis of pregnancy). Which symptom is most characteristic?

Upper right quadrant pain with fever
Nausea and vomiting in the morning
Painless jaundice with dark urine
Intense generalized pruritus, worst on the palms and soles (Correct answer)

Correct answer: Intense generalized pruritus, worst on the palms and soles

The hallmark symptom of intrahepatic cholestasis of pregnancy is intense pruritus, especially on the palms and soles, caused by bile salt accumulation under the skin.

Question 35: A client at 29 weeks gestation is diagnosed with oligohydramnios. The nurse knows this condition is MOST commonly associated with:

Fetal cardiac defects
Maternal diabetes mellitus
Twin-to-twin transfusion syndrome in the recipient twin
Fetal renal agenesis or obstructive uropathies (Correct answer)

Correct answer: Fetal renal agenesis or obstructive uropathies

Oligohydramnios is most commonly caused by fetal renal anomalies (e.g., renal agenesis, posterior urethral valves) because the kidneys produce most amniotic fluid via urine after mid-pregnancy.

Question 36: A client with chronic hypertension becomes pregnant. The nurse knows that which antihypertensive medication is CONTRAINDICATED during pregnancy?

Lisinopril (ACE inhibitor) (Correct answer)
Labetalol
Nifedipine
Methyldopa (Aldomet)

Correct answer: Lisinopril (ACE inhibitor)

ACE inhibitors are teratogenic and can cause fetal renal dysgenesis, oligohydramnios, and neonatal renal failure; they are absolutely contraindicated in pregnancy.

Question 37: Which cultural consideration is most important when screening for postpartum depression?

Use culturally validated screening tools and recognize that some cultures stigmatize mental illness (Correct answer)
Skip screening for clients from cultures that traditionally value emotional stoicism
Only screen clients who are fluent in English
Assume all cultures express postpartum depression with identical symptoms

Correct answer: Use culturally validated screening tools and recognize that some cultures stigmatize mental illness

Cultural beliefs significantly shape how women express and conceptualize perinatal mental health; using culturally validated tools and recognizing stigma ensures equitable and effective screening.

Question 38: A nurse is assessing a client in labor and notes the umbilical cord is visible at the vaginal introitus. Which action should be taken FIRST?

Administer oxygen via face mask
Place the client in Trendelenburg position
Call for emergency assistance immediately
Apply continuous upward pressure on the presenting part to relieve cord compression (Correct answer)

Correct answer: Apply continuous upward pressure on the presenting part to relieve cord compression

Umbilical cord prolapse is an obstetric emergency; the nurse must manually elevate the presenting part off the cord to relieve compression while calling for help and preparing for emergency delivery.

Question 39: Which newborn weight loss in the first few days of life is considered within normal limits?

Up to 10% of birth weight (Correct answer)
Up to 5% of birth weight
Up to 15% of birth weight
Any weight loss is abnormal

Correct answer: Up to 10% of birth weight

A term newborn may lose up to 10% of birth weight in the first 3–5 days due to fluid shifts, meconium passage, and establishing feeding, and should regain birth weight by 10–14 days.

Question 40: A mother is receiving advice from a nurse in a PP unit about lochia and the amount of anticipated lochia drainage. The nurse informs the mother that while the typical dosage of lochia may change, it should never go beyond what is necessary for:

Three peripads per day.
Eight peripads per day. (Correct answer)
Two peripads per day.
One peripad per day.

Correct answer: Eight peripads per day.

Depending on the individual, the recommended daily intake of lochia may range from 4 to 8 peripads. Six peripads are used on average each day. Excessive blood loss during or after the third stage of labor is referred to as postpartum hemorrhage. 500 mL of blood are lost on average after vaginal delivery and 1000 mL with cesarean section.

Question 41: During a prenatal visit at 10 weeks, a client discloses she drinks two glasses of wine per day. The nurse's BEST response is:

Advise the client that no amount of alcohol is known to be safe during pregnancy (Correct answer)
That is acceptable as long as it does not exceed three drinks per day
Reassure her that alcohol only affects the fetus in the third trimester
Suggest switching to beer which is lower in alcohol content

Correct answer: Advise the client that no amount of alcohol is known to be safe during pregnancy

There is no established safe level of alcohol consumption during pregnancy; alcohol crosses the placenta and can cause fetal alcohol spectrum disorders at any gestational age.

Question 42: Which newborn measurement indicates macrosomia and increases risk for birth injuries?

Birth weight of 3,200 g (7 lb 1 oz)
Birth weight greater than 4,000 g (8 lb 13 oz) (Correct answer)
Length of 50 cm
Head circumference of 34 cm

Correct answer: Birth weight greater than 4,000 g (8 lb 13 oz)

Macrosomia is defined as birth weight >4,000 g and is associated with increased risk of shoulder dystocia, fractures, and brachial plexus injury during delivery.

Question 43: About 2 months and 1 week into her pregnancy, the primigravida is being cared for by the nurse. The nurse determines that the client has understood the instructions after describing self-care techniques for typical pregnant discomforts when she says:

“Leg cramps can be alleviated if I put an ice pack on the area.”
“Nausea and vomiting can be decreased if I eat a few crackers before rising.” (Correct answer)
“If I start to leak colostrum, I should cleanse my nipples with soap and water.”
“If I have a vaginal discharge, I should wear nylon underwear.”

Correct answer: “Nausea and vomiting can be decreased if I eat a few crackers before rising.”

Before awakening, munching on dry crackers can help lessen the normal unpleasantness of nausea and vomiting. A high-protein snack right before night and avoiding foods with strong flavors can also be beneficial.

Question 44: A postpartum client's fundus is boggy and displaced to the right of midline. What is the priority nursing action?

Assist client to void or catheterize (Correct answer)
Administer oxytocin IV
Notify the physician immediately
Massage the fundus firmly

Correct answer: Assist client to void or catheterize

A displaced fundus most commonly indicates a full bladder, which must be emptied before fundal massage will be effective.

Question 45: Which medication is CONTRAINDICATED in a breastfeeding patient with postpartum depression?

Lithium carbonate at high doses (Correct answer)
Cognitive behavioral therapy
Paroxetine (Paxil)
Sertraline (Zoloft)

Correct answer: Lithium carbonate at high doses

Lithium is excreted in breast milk in significant concentrations and can cause lithium toxicity in the nursing infant, including hypotonia, bradycardia, and cyanosis.

Question 46: A primigravida at 36 weeks has a blood pressure of 148/96 mmHg on two readings 4 hours apart. She denies headache or visual changes and has trace proteinuria. What condition does this represent?

Preeclampsia without severe features
Normal blood pressure variation in pregnancy
Chronic hypertension
Gestational hypertension (Correct answer)

Correct answer: Gestational hypertension

Gestational hypertension is defined as BP ≥140/90 mmHg after 20 weeks without the proteinuria or end-organ involvement required to diagnose preeclampsia.

Question 47: A postpartum client is diagnosed with deep vein thrombosis (DVT) of the left leg. Which nursing action is contraindicated?

Applying warm moist heat to the affected leg
Elevating the affected extremity
Administering anticoagulant therapy as ordered
Massaging the affected calf to relieve discomfort (Correct answer)

Correct answer: Massaging the affected calf to relieve discomfort

Massaging a leg with suspected or confirmed DVT is contraindicated because it can dislodge the thrombus and cause a pulmonary embolism.

Question 48: At 12 hours of life, a newborn has not passed meconium. Which assessment finding would most concern the nurse?

Abdominal distention with absent bowel sounds (Correct answer)
Presence of vernix in the groin folds
Mild acrocyanosis of the hands and feet
Passage of transitional stool instead of meconium

Correct answer: Abdominal distention with absent bowel sounds

Abdominal distension with absent bowel sounds in a newborn who has not passed meconium may indicate intestinal obstruction such as Hirschsprung disease or meconium ileus.

Question 49: A patient develops eclampsia and begins seizing during labor. What is the nurse's FIRST priority action?

Time and document the seizure
Turn the patient to her side and protect her from injury (Correct answer)
Administer magnesium sulfate IV bolus
Call for emergency assistance immediately

Correct answer: Turn the patient to her side and protect her from injury

The first priority during an eclamptic seizure is patient safety — turning her to the side prevents aspiration and maintains a patent airway while protecting her from self-injury.

Question 50: The nurse assesses a newborn's respiratory rate as 68 breaths per minute consistently over 15 minutes. What condition does this most likely indicate?

Bradypnea requiring immediate resuscitation
Tachypnea suggesting respiratory distress (Correct answer)
Normal respiratory rate for a newborn
Cheyne-Stokes breathing pattern

Correct answer: Tachypnea suggesting respiratory distress

Normal newborn respiratory rate is 30–60 breaths per minute; a sustained rate of 68 breaths per minute is tachypnea indicating potential respiratory distress.

Question 51: A pregnant client at 28 weeks gestation is prescribed the Rh immunoglobulin (RhoGAM) injection. The nurse knows this is indicated because the client is:

Rh-positive with an Rh-positive fetus
Rh-positive with an Rh-negative fetus
Rh-negative with an Rh-negative fetus
Rh-negative with an Rh-positive fetus (Correct answer)

Correct answer: Rh-negative with an Rh-positive fetus

RhoGAM is given to Rh-negative mothers who may be carrying an Rh-positive fetus to prevent isoimmunization.

Question 52: What is the cardinal movement of fetal descent in which the fetal head rotates 45 degrees to align the occiput with the pubic symphysis?

Extension
Flexion
Internal rotation (Correct answer)
External rotation

Correct answer: Internal rotation

Internal rotation aligns the longest diameter of the fetal head with the longest diameter of the pelvic outlet, positioning the occiput anterior under the pubic symphysis for delivery.

Question 53: A newborn requires resuscitation in the delivery room. Epinephrine is administered via the endotracheal tube. What is the correct dose range?

0.5 mg/kg of 1:100,000 concentration
0.1 mg/kg of 1:10,000 concentration
0.01–0.03 mg/kg of 1:1,000 concentration
0.01–0.03 mg/kg of 1:10,000 concentration via IV/IO (0.05–0.1 mg/kg via ETT) (Correct answer)

Correct answer: 0.01–0.03 mg/kg of 1:10,000 concentration via IV/IO (0.05–0.1 mg/kg via ETT)

Per NRP guidelines, IV/IO epinephrine dose is 0.01–0.03 mg/kg of 1:10,000 solution; the endotracheal dose is higher (0.05–0.1 mg/kg) due to less reliable absorption.

Question 54: A breastfeeding client asks why her uterine cramping worsens during nursing. What is the correct explanation?

Infection is causing uterine irritability
Progesterone levels drop sharply during breastfeeding
Oxytocin released during suckling causes uterine contractions (Correct answer)
The uterus is not involuting properly

Correct answer: Oxytocin released during suckling causes uterine contractions

Suckling stimulates oxytocin release from the posterior pituitary, which promotes uterine contractions and involution.

Question 55: A newborn is born to a mother with insulin-dependent diabetes. Which complication is the newborn at HIGHEST risk for in the first hours of life?

Hyperglycemia
Hypoglycemia (Correct answer)
Hypocalcemia
Hypernatremia

Correct answer: Hypoglycemia

Infants of diabetic mothers have pancreatic beta-cell hyperplasia from chronic in utero hyperglycemia; after delivery they lose maternal glucose but continue producing excess insulin, causing hypoglycemia.

Question 56: A primigravida at 36 weeks asks the nurse about warning signs to report immediately. Which symptom is MOST urgent?

Increased vaginal discharge without odor
Sudden severe headache and visual disturbances (Correct answer)
Braxton Hicks contractions every 20 minutes
Mild ankle edema at day's end

Correct answer: Sudden severe headache and visual disturbances

Sudden severe headache and visual changes (scotoma, blurring) are signs of severe preeclampsia or impending eclampsia requiring emergency evaluation.

Question 57: A client in the third trimester reports lying on her back causes dizziness and light-headedness. The nurse explains this is due to:

Increased cardiac output compressing the aorta
Vagal stimulation from Braxton Hicks contractions
Hyperventilation from increased respiratory demand
Compression of the inferior vena cava by the gravid uterus (supine hypotensive syndrome) (Correct answer)

Correct answer: Compression of the inferior vena cava by the gravid uterus (supine hypotensive syndrome)

The gravid uterus compresses the inferior vena cava in the supine position, reducing venous return and cardiac output, causing supine hypotensive syndrome.

Question 58: When performing a gestational age assessment using the Ballard scale, which physical characteristic would indicate a post-term newborn?

Fused eyelids
Smooth, peeling skin with little vernix caseosa (Correct answer)
Abundant lanugo covering the body
Soft, flat ear cartilage

Correct answer: Smooth, peeling skin with little vernix caseosa

Post-term infants typically have dry, peeling, cracked skin with minimal vernix because vernix production decreases as the pregnancy extends beyond 40 weeks.

Question 59: A newborn is assessed and found to have Erb's palsy. Which structure was most likely injured during delivery?

Cervical spinal cord at C3–C4
Facial nerve (cranial nerve VII)
Brachial plexus at C5–C6 nerve roots (Correct answer)
Phrenic nerve at C3–C5

Correct answer: Brachial plexus at C5–C6 nerve roots

Erb's palsy results from injury to the C5–C6 nerve roots of the brachial plexus, typically caused by excessive lateral traction on the head during a difficult delivery.

Question 60: A formula-fed newborn at 2 weeks is taking 2 oz every 3 hours. The mother asks if this is adequate. What is the appropriate nursing response?

Yes, this is consistent with expected intake of approximately 2–3 oz every 3–4 hours for a 2-week-old (Correct answer)
No, the newborn should be taking at least 6 oz per feeding
Reduce feedings to 4 times per day to prevent overfeeding
The newborn needs to be on a strict 4-hour feeding schedule

Correct answer: Yes, this is consistent with expected intake of approximately 2–3 oz every 3–4 hours for a 2-week-old

A formula-fed newborn at 2 weeks typically takes 2–3 oz every 3–4 hours; feeding on demand and watching for satiety cues prevents overfeeding.

Question 61: Which finding is a classic sign of disseminated intravascular coagulation (DIC) in an obstetric client?

Elevated platelet count with normal coagulation studies
Oozing from IV sites, petechiae, and prolonged PT/PTT with low fibrinogen (Correct answer)
Localized deep vein thrombosis
Elevated blood pressure with no bleeding

Correct answer: Oozing from IV sites, petechiae, and prolonged PT/PTT with low fibrinogen

DIC is a consumptive coagulopathy causing simultaneous clotting and bleeding, evidenced by oozing from puncture sites, petechiae, prolonged clotting times, and depleted fibrinogen.

Question 62: Which method is used to verify placement of a nasogastric (NG) tube in a newborn before feeding?

Place the tube end in water to check for bubbling
Aspirate gastric contents and confirm pH ≤5 along with measuring the external tube length (Correct answer)
Rely on the insertion depth measured before placement alone
Inject air and auscultate for a whoosh sound only

Correct answer: Aspirate gastric contents and confirm pH ≤5 along with measuring the external tube length

NG tube placement is verified by pH testing of aspirated gastric contents (pH ≤5 confirms gastric placement) and confirming the external tube length matches pre-insertion measurement.

Question 63: A postpartum patient is receiving oxytocin (Pitocin) IV for uterine atony. Which adverse effect is specific to high-dose oxytocin administration?

Hyperkalemia and peaked T-waves
Hypertension and tachycardia
Water intoxication and hyponatremia (Correct answer)
Respiratory alkalosis

Correct answer: Water intoxication and hyponatremia

Oxytocin has antidiuretic properties similar to ADH; at high doses or with large fluid volumes, it can cause water retention leading to hyponatremia and water intoxication.

Question 64: Approximately 9 days after term, a primigravida in active labor. Before delivery, the customer wants a bilateral pudendal block anesthetic. Which of the following regions identified by the client as the area of alleviation would suggest to the nurse that the teaching was effective after the nurse discusses this sort of anesthetic to the client?

Perineum (Correct answer)
Fundus
Abdomen
Back

Correct answer: Perineum

For vaginal deliveries, a bilateral pudendal block is utilized to reduce pain, mainly in the perineum and vagina. For an episiotomy and subsequent repair, a pudendal block anesthetic is appropriate.

Question 65: A nurse is caring for a premature newborn at 30 weeks gestation who requires surfactant therapy. Which condition is this treatment intended to address?

Bronchopulmonary dysplasia
Meconium aspiration syndrome
Respiratory distress syndrome (RDS) caused by insufficient surfactant production (Correct answer)
Transient tachypnea of the newborn (TTN)

Correct answer: Respiratory distress syndrome (RDS) caused by insufficient surfactant production

Preterm infants lack sufficient surfactant, leading to alveolar collapse and RDS; exogenous surfactant therapy reduces surface tension, improves lung compliance, and decreases mortality.

Question 66: A patient's labor has been augmented with oxytocin. She is now 10 cm dilated and pushing. The fetal head has not advanced after 2 hours of pushing in a nulliparous patient. This is termed:

Precipitous labor
Arrested descent (Correct answer)
Active phase arrest
Prolonged latent phase

Correct answer: Arrested descent

Arrested descent is diagnosed when there is no progress in fetal descent after 2 hours of pushing in a nulliparous patient despite adequate uterine contractions.

Question 67: A newborn is diagnosed with hypoxic-ischemic encephalopathy (HIE). Which therapeutic intervention has been shown to improve neurological outcomes?

Therapeutic hypothermia (cooling therapy) (Correct answer)
High-frequency ventilation
Early gavage feeding
Systemic corticosteroid administration

Correct answer: Therapeutic hypothermia (cooling therapy)

Therapeutic hypothermia (cooling to 33–34°C for 72 hours) initiated within 6 hours of birth reduces neuronal apoptosis and improves neurological outcomes in term infants with moderate-to-severe HIE.

Question 68: A nurse is assessing a newborn for developmental dysplasia of the hip (DDH). Which maneuver assesses for a dislocatable hip?

Ortolani maneuver — abduction with upward pressure detects a 'clunk' of reduction
Trendelenburg test — single-leg stance to assess gluteal muscle strength
Barlow maneuver — adduction with downward pressure assesses for dislocation (Correct answer)
Galeazzi sign — unequal knee heights assessed with hips and knees flexed

Correct answer: Barlow maneuver — adduction with downward pressure assesses for dislocation

The Barlow maneuver adducts and applies posterior pressure to determine if the femoral head can be dislocated out of the acetabulum.

Question 69: A client with postpartum depression wishes to continue breastfeeding. Which antidepressant is generally considered the safest first-line choice for breastfeeding mothers?

Paroxetine (Paxil)
Sertraline (Zoloft) (Correct answer)
Fluoxetine (Prozac)
Venlafaxine (Effexor)

Correct answer: Sertraline (Zoloft)

Sertraline (Zoloft) is the preferred SSRI for breastfeeding mothers with PPD due to minimal transfer into breast milk and the most extensive infant safety data.

Question 70: A client at 39 weeks reports regular contractions every 4 minutes lasting 60 seconds. Cervical exam shows 5 cm dilation, 80% effacement, and -1 station. What stage and phase of labor is she in?

First stage, latent phase
Transition phase
First stage, active phase (Correct answer)
Second stage

Correct answer: First stage, active phase

Active phase of the first stage of labor is defined by cervical dilation from 6 cm, but 5 cm with regular contractions and significant effacement is consistent with active labor in many clinical frameworks.

Question 71: A patient at 28 weeks gestation is in preterm labor. Betamethasone is ordered. What is the primary purpose of this medication?

To accelerate fetal lung maturity and surfactant production (Correct answer)
To prevent postpartum hemorrhage after delivery
To stop uterine contractions and prevent preterm birth
To treat Group B Streptococcus infection

Correct answer: To accelerate fetal lung maturity and surfactant production

Antenatal betamethasone (corticosteroid) given between 24–34 weeks gestation promotes fetal surfactant production, reducing the severity of respiratory distress syndrome after preterm birth.

Question 72: Indomethacin is prescribed as a tocolytic for a patient at 28 weeks in preterm labor. Which fetal effect must the nurse be aware of with prolonged use?

Premature closure of the ductus arteriosus (Correct answer)
Fetal anemia due to suppressed erythropoiesis
Fetal macrosomia due to altered insulin secretion
Accelerated fetal bone development

Correct answer: Premature closure of the ductus arteriosus

Indomethacin, a prostaglandin synthetase inhibitor, can cause constriction or premature closure of the ductus arteriosus, especially with use beyond 32 weeks or for more than 48 hours.

Question 73: Which of the following is the strongest risk factor for developing postpartum depression?

Primiparity
Cesarean section delivery
History of depression or mood disorders (Correct answer)
Maternal age over 35

Correct answer: History of depression or mood disorders

A personal or family history of depression or mood disorders is the strongest predictive risk factor for developing postpartum depression.

Question 74: A postpartum client has a fourth-degree perineal laceration. Which intervention is most important for comfort and healing?

Apply ice packs continuously for 72 hours
Administer stool softeners and encourage adequate fluid intake (Correct answer)
Restrict oral fluid intake to reduce bowel movements
Limit ambulation for the first 48 hours

Correct answer: Administer stool softeners and encourage adequate fluid intake

Stool softeners and fluids prevent constipation and straining, which is critical with a fourth-degree laceration that extends into the rectal sphincter.

Question 75: A newborn is diagnosed with meconium aspiration syndrome (MAS). Which clinical finding is most characteristic?

Normal oxygen saturation without supplemental oxygen
Clear lung fields on chest X-ray
Barrel-shaped chest and patchy infiltrates on X-ray with hyperinflation (Correct answer)
Bilateral pleural effusions

Correct answer: Barrel-shaped chest and patchy infiltrates on X-ray with hyperinflation

MAS causes air trapping from ball-valve obstruction by meconium particles, resulting in a barrel-shaped chest and the characteristic patchy, hyperinflated appearance on chest X-ray.

Question 76: During a client's admittance evaluation who is carrying twins, a nurse is gathering data. The client informs the nurse that she has a healthy 5-year-old child who was born at 37 weeks and that she has no prior history of abortion or fetal demise. The GTPAL for this client would be noted by the nurse as follows:

Gravida 3, para 2001
Gravida 1, para 1101
Gravida 2, para 1001 (Correct answer)
Gravida 2, para 0101

Correct answer: Gravida 2, para 1001

The abbreviation GTPAL can be used to denote pregnancy outcomes. Our GTPAL Guide can be used to learn more about obstetric history. - ""G"" stands for gravidity, or the quantity of pregnancies. - ""T"" stands for term births, or the number of babies delivered at term (37 weeks or later). - Preterm births are those occurring between 20 and 36 weeks of pregnancy, or ""P"" births. - ""A"" refers to abortions, miscarriages, and pre-20 week losses. - ""L"" stands for live births, or the quantity of children born alive.

Question 77: A patient at 20 weeks gestation is diagnosed with an incompetent cervix and undergoes cervical cerclage. Which discharge instruction should the nurse provide?

Expect some cervical bleeding for 4–6 weeks
Report any uterine contractions, bleeding, or ruptured membranes immediately (Correct answer)
Avoid all prenatal vitamins after the procedure
Resume all normal activities including sexual intercourse

Correct answer: Report any uterine contractions, bleeding, or ruptured membranes immediately

After cerclage placement, patients must be educated to report contractions, bleeding, or membrane rupture immediately as these may indicate cerclage failure or preterm labor.

Question 78: A nurse is preparing discharge teaching about resuming sexual intercourse postpartum. What is the standard recommendation?

Wait at least 6 weeks or until cleared by the provider and lochia has ceased (Correct answer)
Avoid intercourse until the next menstrual period returns
Wait exactly 6 weeks regardless of healing status
Resume whenever the client feels physically comfortable, usually within 1 week

Correct answer: Wait at least 6 weeks or until cleared by the provider and lochia has ceased

Most providers recommend waiting until lochia has stopped and perineal healing is complete, typically around 6 weeks and after provider clearance.

Question 79: The nurse observes clots in the lochia while conducting a PP assessment on the client. After looking at the clots closely, the nurse determines that they are greater than 1 cm. Which of the following nursing interventions is ideal?

Reassess the client in 2 hours.
Encourage increased intake of fluids.
Document the findings.
Notify the physician. (Correct answer)

Correct answer: Notify the physician.

Normal results of blood pooling in the vagina include a few tiny clots in the first one to two days following delivery. Larger than 1 cm clots are regarded as abnormal. To stop additional bleeding, the cause of these clots, such as uterine atony or residual placental pieces, must be identified and addressed.

Question 80: A client in active labor has a fetal heart rate (FHR) baseline of 170 bpm for 15 minutes. Which nursing action is the priority?

Increase IV fluid rate
Notify the provider immediately (Correct answer)
Administer oxygen via face mask at 8–10 L/min
Reposition the client to the left lateral position

Correct answer: Notify the provider immediately

A baseline FHR above 160 bpm for ≥10 minutes is tachycardia and requires immediate provider notification to evaluate for infection, fetal distress, or medication effects.

Question 81: A breastfed newborn has a bilirubin level of 18 mg/dL at 5 days of life. The pediatrician suspects breast milk jaundice. Which action is most appropriate?

Permanently discontinue breastfeeding
Administer exchange transfusion immediately
Temporarily interrupt breastfeeding for 24–48 hours and provide formula
Increase breastfeeding frequency to 10–12 times per day (Correct answer)

Correct answer: Increase breastfeeding frequency to 10–12 times per day

For breast milk jaundice with non-critical bilirubin levels, increasing breastfeeding frequency to 10–12 times per day promotes bilirubin excretion and is the preferred first intervention.

Question 82: Which position is most appropriate for a client with a prolapsed umbilical cord while awaiting emergency cesarean delivery?

Left lateral decubitus (Sims) position
Trendelenburg or knee-chest position (Correct answer)
Right lateral with a wedge under the hip
High Fowler's position

Correct answer: Trendelenburg or knee-chest position

Trendelenburg or knee-chest position uses gravity to relieve pressure on the prolapsed cord by allowing the fetal presenting part to move away from the cord.

Question 83: A nurse is assessing a postpartum client 12 hours after delivery. The fundus is found 2 cm above the umbilicus and deviated to the right. What is the priority nursing intervention?

Notify the physician of uterine atony
Assist the client to empty her bladder (Correct answer)
Massage the fundus vigorously
Administer oxytocin immediately

Correct answer: Assist the client to empty her bladder

A fundus deviated to the right and above the umbilicus indicates a full bladder displacing the uterus, so the client should void or be catheterized.

Question 84: A patient with gestational diabetes is at 38 weeks gestation. Her fasting glucose readings have been 95–105 mg/dL on dietary management alone. What intervention is indicated?

Schedule immediate induction of labor
Initiate insulin therapy as dietary control has failed (Correct answer)
Switch to oral hypoglycemic agents such as glyburide
Continue dietary management and recheck at 40 weeks

Correct answer: Initiate insulin therapy as dietary control has failed

Fasting glucose levels above 95 mg/dL despite dietary management indicate inadequate blood glucose control, and insulin therapy should be initiated to protect fetal outcomes.

Question 85: A postpartum client who had a cesarean birth asks when she can expect her bowel function to return. What should the nurse tell her?

Within 12 hours, because surgery stimulates bowel peristalsis
Usually within 2–3 days, assisted by ambulation and passage of flatus (Correct answer)
Only after a Fleet enema is administered
Not until she is fully off IV fluids

Correct answer: Usually within 2–3 days, assisted by ambulation and passage of flatus

Post-cesarean ileus typically resolves within 2–3 days; early ambulation and adequate hydration help restore peristalsis.

Question 86: A nurse is teaching a mother about breast engorgement. Which measure is most effective for relief?

Applying cabbage leaves permanently without feeding
Binding the breasts tightly to suppress milk production
Restricting fluid intake to reduce milk production
Frequent feeding or pumping to empty the breasts, with warm compresses before and cold packs after feeds (Correct answer)

Correct answer: Frequent feeding or pumping to empty the breasts, with warm compresses before and cold packs after feeds

Frequent, effective milk removal through feeding or pumping is the most effective treatment for engorgement; warmth before feeds promotes let-down and cold packs after reduce swelling.

Question 87: A patient at 32 weeks gestation is admitted with preterm premature rupture of membranes (PPROM). She is GBS-negative. What is the priority nursing intervention?

Initiate fetal monitoring and assess for signs of infection and cord prolapse (Correct answer)
Prepare for immediate induction of labor
Administer tocolytics to stop preterm contractions
Place the patient in Trendelenburg position permanently

Correct answer: Initiate fetal monitoring and assess for signs of infection and cord prolapse

With PPROM, priority nursing care involves continuous fetal monitoring for non-reassuring patterns including cord prolapse, along with assessment for chorioamnionitis (infection).

Question 88: Which newborn screening test is mandatory in all US states and detects a condition that causes intellectual disability if untreated?

Phenylketonuria (PKU) blood spot screening (Correct answer)
Direct Coombs test
Glucose-6-phosphate dehydrogenase test
Cystic fibrosis sweat chloride test

Correct answer: Phenylketonuria (PKU) blood spot screening

PKU screening via heel stick blood spot is mandated in all US states; untreated PKU causes severe intellectual disability due to phenylalanine accumulation, but dietary treatment prevents neurological damage.

Question 89: Why is vitamin K (phytonadione) administered to the newborn at birth?

To prevent neonatal jaundice
To boost the newborn's immune system
To prevent Group B Streptococcus infection
Newborns have low vitamin K stores and lack intestinal flora to produce it, placing them at risk for hemorrhagic disease (Correct answer)

Correct answer: Newborns have low vitamin K stores and lack intestinal flora to produce it, placing them at risk for hemorrhagic disease

Neonates are born with low vitamin K due to poor placental transfer and lack of intestinal bacteria; without the injection, they are at risk for vitamin K deficiency bleeding (VKDB).

Question 90: A nurse assesses a newborn's blood glucose 30 minutes after birth. The result is 38 mg/dL. What should the nurse do first?

Document the finding as normal and continue routine care
Administer IV dextrose immediately
Report the finding to the provider and await orders before acting
Initiate early feeding (breast or formula) and recheck glucose in 30–60 minutes (Correct answer)

Correct answer: Initiate early feeding (breast or formula) and recheck glucose in 30–60 minutes

A blood glucose <47 mg/dL in a newborn is hypoglycemia; the first-line treatment is early oral feeding, followed by retesting to confirm response before escalating to IV dextrose.

Question 91: Which assessment finding indicates successful postpartum adaptation of the urinary system?

Urine output less than 200 mL in 8 hours
Urinary retention requiring catheterization at 4 hours postpartum
Voiding at least 150 mL with first void after delivery (Correct answer)
Concentrated urine with specific gravity above 1.030

Correct answer: Voiding at least 150 mL with first void after delivery

The client should void spontaneously within 6–8 hours postpartum; a void of at least 150 mL suggests adequate bladder function.

Question 92: Which nursing action prevents kernicterus in a newborn with rising bilirubin levels?

Initiating phototherapy promptly when bilirubin reaches the treatment threshold per nomogram (Correct answer)
Administering oral phenobarbital to accelerate bilirubin clearance
Waiting 48 hours to see if bilirubin levels naturally decline
Restricting feedings to reduce bilirubin production

Correct answer: Initiating phototherapy promptly when bilirubin reaches the treatment threshold per nomogram

Prompt initiation of phototherapy when bilirubin reaches the age-specific treatment threshold is the key intervention to prevent bilirubin neurotoxicity (kernicterus).

Question 93: A preterm neonate has a patent ductus arteriosus (PDA). Which sign would the nurse observe during assessment?

Friction rub heard over the apex
Quiet precordium with no murmur
Diastolic murmur at the right sternal border
Continuous machinery-like murmur at the left upper sternal border (Correct answer)

Correct answer: Continuous machinery-like murmur at the left upper sternal border

A PDA produces a characteristic continuous machinery-like murmur heard best at the left infraclavicular area due to continuous shunting of blood from the aorta to pulmonary artery.

Question 94: A patient with preeclampsia with severe features delivers at 34 weeks. Magnesium sulfate is continued postpartum. For how long is magnesium typically continued after delivery for seizure prophylaxis?

24–48 hours postpartum (Correct answer)
72 hours postpartum
12 hours postpartum
6–8 hours postpartum

Correct answer: 24–48 hours postpartum

Magnesium sulfate for seizure prophylaxis is typically continued for 24–48 hours postpartum in preeclampsia with severe features, as the risk for eclamptic seizures persists after delivery.

Question 95: A nurse notes a white, cheese-like substance covering a newborn's skin. What is this substance and what should the nurse do?

Milia — apply moisturizing lotion
Vernix caseosa — remove it completely with the first bath
Vernix caseosa — leave it in place as it protects the skin and promotes colonization with beneficial bacteria (Correct answer)
Lanugo — document only, no action needed

Correct answer: Vernix caseosa — leave it in place as it protects the skin and promotes colonization with beneficial bacteria

Vernix caseosa is a protective biofilm that moisturizes newborn skin, has antimicrobial properties, and should be left in place or gently massaged into the skin.

Question 96: During the second stage of labor, a nurse observes the fetal head beginning to deliver and notes the cord is wrapped around the neck. The cord cannot be slipped over the head. What is the nurse's next action?

Instruct the client to push harder with the next contraction
Apply fundal pressure to expedite delivery
Perform an emergency cesarean section
Double-clamp and cut the cord before delivery (Correct answer)

Correct answer: Double-clamp and cut the cord before delivery

When a nuchal cord is too tight to slip over the head, the nurse should double-clamp and cut it to allow safe delivery of the baby.

Question 97: A nurse is developing a plan of care for a client diagnosed with postpartum depression. Which intervention is the priority?

Assess for suicidal ideation and risk of harm to self or infant (Correct answer)
Instruct the client to exercise daily to improve mood
Encourage exclusive breastfeeding to promote bonding
Recommend formula feeding to allow the mother more sleep

Correct answer: Assess for suicidal ideation and risk of harm to self or infant

Safety assessment for suicidal ideation or risk of harm to the infant is always the priority intervention when caring for a client with postpartum depression.

Question 98: A pregnant patient at 28 weeks is diagnosed with gestational diabetes after a 3-hour glucose tolerance test. Which dietary change is the first-line management?

Unrestricted diet with metformin supplementation
Carbohydrate-controlled diet with 3 meals and 2–3 snacks (Correct answer)
High-protein, fat-only diet to avoid all sugars
Total fasting until insulin therapy is initiated

Correct answer: Carbohydrate-controlled diet with 3 meals and 2–3 snacks

Medical nutrition therapy with carbohydrate counting (typically 45–60 g per meal, 15–30 g per snack) distributed across small frequent meals is the first-line treatment for gestational diabetes.

Question 99: Which symptom distinguishes placental abruption from placenta previa?

Painless bright red vaginal bleeding
Absent fetal movement without bleeding
Rupture of membranes with a gush of fluid
Painful, dark red vaginal bleeding with uterine rigidity (Correct answer)

Correct answer: Painful, dark red vaginal bleeding with uterine rigidity

Placental abruption presents with painful, dark red vaginal bleeding (may be concealed) and a rigid, board-like uterus due to retroplacental hemorrhage.

Question 100: The nurse is caring for a patient in labor whose membranes rupture spontaneously. The fluid is green-tinged. What is the priority nursing action?

Document the color and continue routine monitoring
Assess the fetal heart rate immediately (Correct answer)
Notify dietary to hold the next meal
Perform a vaginal exam to check dilation

Correct answer: Assess the fetal heart rate immediately

Meconium-stained amniotic fluid indicates possible fetal stress, so immediate fetal heart rate assessment is the priority to detect fetal compromise.

Question 101: A newborn with suspected sepsis has a white blood cell count of 4,000 cells/mcL. What does this finding indicate?

Leukocytosis suggesting bacterial infection
Normal neonatal WBC value, no concern
Leukopenia, which is an ominous sign of overwhelming infection (Correct answer)
Lymphocytosis suggesting viral infection

Correct answer: Leukopenia, which is an ominous sign of overwhelming infection

A WBC below 5,000 cells/mcL (leukopenia) in a neonate indicates the bone marrow cannot keep up with bacterial consumption of white cells, suggesting overwhelming sepsis with poor prognosis.

Question 102: Which finding on a postpartum assessment at 24 hours is considered normal?

Blood pressure of 90/50 mmHg
Respiratory rate of 24 breaths/min
Pulse rate of 55 beats/min (Correct answer)
Temperature of 38.8°C (101.8°F)

Correct answer: Pulse rate of 55 beats/min

Postpartum bradycardia (50–70 bpm) is a normal physiologic response in the first week after delivery due to increased stroke volume.

Question 103: A client reports intrusive memories of her traumatic delivery, avoids anything that reminds her of the birth, and is hypervigilant 6 weeks postpartum. Which condition does the nurse suspect?

Postpartum psychosis
Postpartum PTSD (Correct answer)
Postpartum anxiety
Postpartum depression

Correct answer: Postpartum PTSD

Intrusive memories, avoidance behaviors, and hypervigilance following a traumatic birth experience are hallmark diagnostic symptoms of postpartum PTSD.

Question 104: A client at 18 weeks gestation asks about amniocentesis. The nurse explains the PRIMARY purpose of amniocentesis in the second trimester is to:

Measure fetal blood glucose
Assess fetal lung maturity
Determine placental location
Evaluate fetal chromosomal abnormalities (Correct answer)

Correct answer: Evaluate fetal chromosomal abnormalities

Second-trimester amniocentesis is primarily used for genetic diagnosis of chromosomal abnormalities such as Down syndrome (trisomy 21).

Question 105: Which laboratory test monitors the effectiveness of phototherapy for neonatal jaundice?

Arterial blood gas every 8 hours
Complete blood count every 12 hours
Serial total serum bilirubin (TSB) levels every 4–6 hours during therapy (Correct answer)
Direct Coombs test daily

Correct answer: Serial total serum bilirubin (TSB) levels every 4–6 hours during therapy

Serial total serum bilirubin levels guide phototherapy management; if TSB continues to rise despite therapy, exchange transfusion may be needed.

Question 106: What is the expected weight loss considered normal in a newborn during the first week of life?

Up to 15% of birth weight
Up to 3% of birth weight
Up to 7–10% of birth weight (Correct answer)
No weight loss is normal

Correct answer: Up to 7–10% of birth weight

Newborns typically lose up to 7–10% of birth weight in the first few days due to fluid shifts and meconium passage; birth weight is usually regained by 10–14 days.

Question 107: A client at 30 weeks gestation is scheduled for a nonstress test (NST). The nurse explains the test is REACTIVE (normal) when:

Fetal heart rate decelerations follow uterine contractions
No fetal movement is detected in 30 minutes
Baseline fetal heart rate is 110 bpm with no variability
Two or more fetal heart rate accelerations of 15 bpm lasting 15 seconds occur within 20 minutes (Correct answer)

Correct answer: Two or more fetal heart rate accelerations of 15 bpm lasting 15 seconds occur within 20 minutes

A reactive NST requires at least two FHR accelerations of ≥15 bpm above baseline lasting ≥15 seconds within 20 minutes, indicating fetal well-being.

Question 108: A postpartum patient develops a temperature of 38.4°C (101.1°F) on day 2 after a cesarean birth. She has uterine tenderness and foul-smelling lochia. What does this indicate?

Normal postoperative fever response
Mastitis requiring warm compresses
Wound dehiscence requiring surgical consultation
Endometritis requiring antibiotic therapy (Correct answer)

Correct answer: Endometritis requiring antibiotic therapy

Fever after the first 24 hours postpartum with uterine tenderness and malodorous lochia is characteristic of endometritis, a uterine infection requiring broad-spectrum antibiotic treatment.

Question 109: Which herbal supplement is commonly believed to increase milk supply but has limited evidence and potential risks?

Chamomile
Fenugreek (Correct answer)
Ginger root
Echinacea

Correct answer: Fenugreek

Fenugreek is widely used as a galactagogue (milk-supply booster) but evidence is limited and inconsistent; it can cause maple syrup odor in urine and sweat and may affect blood sugar.

Question 110: Which finding in a newborn's urinary output during the first 48 hours is a concern for dehydration?

Uric acid crystals (brick-red staining) on the diaper
6–8 wet diapers in 24 hours
Fewer than 1–2 wet diapers in 24 hours (Correct answer)
Pale yellow urine

Correct answer: Fewer than 1–2 wet diapers in 24 hours

Fewer than 1–2 wet diapers in the first 24–48 hours indicates inadequate fluid intake and possible dehydration, especially in breastfed infants.

Question 111: A patient receives terbutaline for preterm labor. Which maternal side effect requires the nurse to notify the healthcare provider immediately?

Mild headache and facial flushing
Mild tremors and palpitations
Transient nausea and diaphoresis
Heart rate of 130 bpm with chest pain (Correct answer)

Correct answer: Heart rate of 130 bpm with chest pain

Tachycardia above 120 bpm with chest pain may indicate cardiac dysrhythmia or pulmonary edema, serious complications of terbutaline that require immediate medical evaluation.

Question 112: A patient at 30 weeks gestation in preterm labor receives nifedipine as a tocolytic. Which side effect should the nurse monitor for?

Hyperglycemia and urinary retention
Bronchoconstriction and dyspnea
Hypertension and bradycardia
Hypotension, flushing, and headache (Correct answer)

Correct answer: Hypotension, flushing, and headache

Nifedipine, a calcium channel blocker used as a tocolytic, causes vasodilation resulting in hypotension, flushing, and headache as its primary side effects.

Question 113: Which assessment finding in a newborn at 24 hours of life requires immediate provider notification?

Acrocyanosis of the hands and feet
Respiratory rate of 40 breaths per minute
Passage of meconium stool
Respiratory rate of 68 breaths per minute with grunting (Correct answer)

Correct answer: Respiratory rate of 68 breaths per minute with grunting

A respiratory rate >60 breaths per minute with grunting indicates respiratory distress and requires immediate provider notification to evaluate for infection or respiratory pathology.

Question 114: A client at 32 weeks gestation presents with a blood pressure of 158/106 mmHg, proteinuria of 2+, and severe headache. Which condition does the nurse suspect?

Gestational hypertension
HELLP syndrome
Severe preeclampsia (Correct answer)
Chronic hypertension

Correct answer: Severe preeclampsia

Severe preeclampsia is characterized by BP ≥160/110 mmHg on two occasions, significant proteinuria, and severe features such as headache, visual changes, or right upper quadrant pain.

Question 115: The nurse assesses a client 30 minutes after epidural placement and notes the blood pressure has dropped from 118/72 to 88/52 mmHg. What is the priority intervention?

Increase IV fluid infusion rate and reposition to left lateral position (Correct answer)
Place the client in Trendelenburg position
Administer epinephrine IV push
Discontinue the epidural catheter

Correct answer: Increase IV fluid infusion rate and reposition to left lateral position

Epidural-induced hypotension is treated first with IV fluid bolus and left lateral positioning to displace the uterus off the vena cava and restore venous return.

Question 116: A nurse notes a newborn's axillary temperature is 36.1°C (97°F) at 2 hours of life. What is the priority intervention?

Notify the provider immediately for sepsis workup
Administer warm IV fluids
Encourage skin-to-skin contact with the mother only
Place the newborn under a radiant warmer and reassess in 30 minutes (Correct answer)

Correct answer: Place the newborn under a radiant warmer and reassess in 30 minutes

Neonatal hypothermia (temperature <36.5°C) is managed initially by placing the infant under a radiant warmer to restore normothermia and prevent metabolic complications.

Question 117: A client scores 14 on the Edinburgh Postnatal Depression Scale at her 6-week postpartum visit. What is the nurse's priority action?

Conduct further assessment including evaluation for suicidal ideation (Correct answer)
Schedule a routine follow-up appointment in 4 weeks
Reassure the client that this score is within normal limits
Recommend herbal remedies for mood improvement

Correct answer: Conduct further assessment including evaluation for suicidal ideation

A score of 14 on the EPDS is significantly above the threshold of 10, indicating serious risk that requires immediate comprehensive assessment including suicide risk evaluation.

Question 118: Which statement by a postpartum client indicates she understands teaching about postpartum depression (PPD) risk?

'Baby blues and PPD are the same condition.'
'PPD symptoms only appear in the first week after delivery.'
'I should call my provider if I feel overwhelmed or hopeless after going home.' (Correct answer)
'PPD only occurs in women with a history of mental illness.'

Correct answer: 'I should call my provider if I feel overwhelmed or hopeless after going home.'

Clients should be instructed to report persistent sadness, hopelessness, or inability to care for the baby, as PPD can develop up to one year postpartum.

Question 119: At what age should solid foods be introduced for a formula-fed or breastfed infant according to current guidelines?

8 months of age to maximize gut maturity
Around 6 months of age, when the infant shows developmental readiness (Correct answer)
4 months of age regardless of readiness
3 months, starting with rice cereal in the bottle

Correct answer: Around 6 months of age, when the infant shows developmental readiness

Both the AAP and WHO recommend introducing solid foods around 6 months when the infant can sit with minimal support, has lost the tongue-thrust reflex, and shows interest in food.

Question 120: A patient at 39 weeks gestation is admitted in active labor. Her GBS (Group B Streptococcus) status is positive. What is the priority nursing intervention?

Obtain a vaginal culture for confirmation
Prepare for immediate cesarean delivery
Restrict oral intake and apply fetal monitor
Initiate IV antibiotic prophylaxis as ordered (Correct answer)

Correct answer: Initiate IV antibiotic prophylaxis as ordered

GBS-positive patients require IV antibiotic prophylaxis (typically penicillin G) during labor to prevent vertical transmission to the neonate.

Question 121: The nurse is teaching a new parent about the newborn's umbilical cord care. Which instruction is most current and evidence-based?

Apply antibiotic ointment to the cord base daily
Allow the cord to dry naturally and keep it clean and dry (Correct answer)
Apply alcohol to the cord stump with each diaper change
Keep the cord stump moist with petroleum jelly

Correct answer: Allow the cord to dry naturally and keep it clean and dry

Current evidence-based guidelines recommend dry cord care — keeping the stump clean and dry — as it promotes natural separation without increasing infection risk.

Question 122: A newborn is ordered to receive ampicillin and gentamicin for suspected sepsis. Which nursing assessment is essential before administering gentamicin?

Blood glucose level
Head circumference measurement
Liver function tests
Serum creatinine and BUN to assess renal function, and urine output (Correct answer)

Correct answer: Serum creatinine and BUN to assess renal function, and urine output

Gentamicin is nephrotoxic and ototoxic; renal function (creatinine, BUN, urine output) must be assessed before each dose, and peak/trough levels monitored to prevent toxicity.

Question 123: A woman who has just given birth to a healthy newborn baby is about to receive postpartum care from a postpartum nurse. The nurse intends to take the mother's vital signs in the early postpartum period:

Every 15 minutes during the first hour and then every 30 minutes for the next two hours. (Correct answer)
Every hour for the first 2 hours and then every 4 hours.
Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours.
Every 30 minutes during the first hour and then every hour for the next two hours.

Correct answer: Every 15 minutes during the first hour and then every 30 minutes for the next two hours.

The first 6 to 12 hours postpartum are considered to be the first or acute stage. There is a chance for urgent emergencies such postpartum hemorrhage, uterine inversion, amniotic fluid embolism, and eclampsia during this period of fast transformation.

Question 124: A nurse measures the fetal heart rate at the 38-week prenatal checkup. Which of the following observations leads the nurse to conclude that the fetal heart rate is normal?

100 BPM
150 BPM (Correct answer)
80 BPM
180 BPM

Correct answer: 150 BPM

The fetal heart rate varies according to gestational age and is between 160 and 170 beats per minute (BPM) in the first trimester before slowing down to 120 to 160 BPM close or at term. When the uterus is at rest and the fetal heart rate is between 120 and 160 BPM at or near term, the fetus may be in distress.

Question 125: A patient is admitted with hyperemesis gravidarum. Which nursing intervention is the highest priority?

Assess hydration status and initiate IV fluid replacement (Correct answer)
Encourage small frequent oral meals immediately
Teach relaxation techniques to manage nausea
Administer antiemetics before assessing dehydration

Correct answer: Assess hydration status and initiate IV fluid replacement

Hyperemesis gravidarum causes severe dehydration and electrolyte imbalances; assessment of hydration status and IV fluid/electrolyte replacement is the immediate priority.

Question 126: A patient at 38 weeks gestation has HELLP syndrome. Which laboratory finding is characteristic of this condition?

Hemolysis, elevated liver enzymes, and low platelets (Correct answer)
Elevated platelets and decreased hemoglobin
Low liver enzymes and elevated creatinine
Elevated white blood cell count and low bilirubin

Correct answer: Hemolysis, elevated liver enzymes, and low platelets

HELLP syndrome is defined by its acronym: Hemolysis, Elevated Liver enzymes (AST/ALT), and Low Platelets (<100,000/mcL), representing a severe variant of preeclampsia.

Question 127: A postpartum client develops a temperature of 38.5°C (101.3°F) on day 3. Which source of infection should the nurse assess first?

Breast tissue
Perineal wound
Endometrium (Correct answer)
Urinary tract

Correct answer: Endometrium

Endometritis is the most common cause of postpartum fever after the first 24 hours and is characterized by uterine tenderness and foul-smelling lochia.

Question 128: A mother with mastitis asks if she should stop breastfeeding. What is the correct nursing response?

Discontinue breastfeeding and start formula feeding
Breastfeed only on the unaffected side
Stop breastfeeding immediately to rest the breast
Continue breastfeeding or pumping frequently — stopping can worsen infection and lead to abscess formation (Correct answer)

Correct answer: Continue breastfeeding or pumping frequently — stopping can worsen infection and lead to abscess formation

Continued, frequent milk removal is essential during mastitis to prevent worsening infection and abscess formation; antibiotics treat the infection while breastfeeding continues.

Question 129: A term newborn is delivered and placed on the mother's abdomen. The nurse's initial assessment reveals the baby is breathing but has central cyanosis. What is the priority action?

Administer blow-by oxygen and reassess within 60 seconds (Correct answer)
Transfer to the NICU without delay
Begin chest compressions immediately
Stimulate the infant vigorously by rubbing the back

Correct answer: Administer blow-by oxygen and reassess within 60 seconds

Central cyanosis in a breathing newborn warrants supplemental oxygen delivery (blow-by) and immediate reassessment to determine if further resuscitation is needed.

Question 130: Which finding in a newborn at 24 hours of life requires immediate reporting to the provider?

Positive Babinski reflex
Caput succedaneum over the occiput
Respiratory rate of 68 breaths/min at rest (Correct answer)
Acrocyanosis of hands and feet

Correct answer: Respiratory rate of 68 breaths/min at rest

A resting respiratory rate above 60 breaths/min (tachypnea) in a newborn is abnormal and may indicate respiratory distress requiring immediate evaluation.

Question 131: A nurse is providing discharge education to a postpartum client. Which statement by the client indicates correct understanding of perinatal mental health warning signs?

I should feel back to normal within 24 hours of delivery.
It is normal to hear my baby crying when the baby is not crying.
I should call my provider if I feel sad or overwhelmed for more than 2 weeks. (Correct answer)
Mood swings after birth mean I will definitely develop postpartum depression.

Correct answer: I should call my provider if I feel sad or overwhelmed for more than 2 weeks.

Persistent sadness or overwhelm lasting more than 2 weeks warrants contacting a healthcare provider as it may indicate PPD requiring treatment.

Question 132: A postpartum client reports intense worry about her baby's health, inability to sleep even when the baby sleeps, and uncontrollable catastrophic thoughts. Which condition does the nurse suspect?

Postpartum depression
Postpartum anxiety (Correct answer)
Postpartum psychosis
Postpartum blues

Correct answer: Postpartum anxiety

Postpartum anxiety is characterized by excessive worry, intrusive thoughts, and inability to relax, and is clinically distinct from postpartum depression.

Question 133: A patient is diagnosed with a postpartum deep vein thrombosis (DVT) of the left leg. Which assessment finding is consistent with this diagnosis?

Bilateral leg edema with cool, pale skin
Unilateral leg warmth, redness, edema, and pain with dorsiflexion (Correct answer)
Superficial varicosities with bilateral calf cramps
Absence of pedal pulses bilaterally

Correct answer: Unilateral leg warmth, redness, edema, and pain with dorsiflexion

DVT presents with unilateral signs because a thrombus forms in one vessel; warmth, erythema, edema, and calf pain with dorsiflexion (Homan's sign) are classic but not always reliable indicators.

Question 134: A client at 34 weeks gestation is admitted with abruptio placentae. Which assessment finding distinguishes abruption from placenta previa?

Rigid, board-like abdomen with dark-red bleeding (Correct answer)
Soft, nontender uterus with heavy bleeding
Painless, bright-red vaginal bleeding
Fetal heart rate accelerations with movement

Correct answer: Rigid, board-like abdomen with dark-red bleeding

Abruptio placentae typically presents with sudden-onset, severe abdominal pain and a rigid, board-like uterus due to retroplacental hemorrhage, unlike the painless bleeding of previa.

Question 135: A client who delivered 48 hours ago reports painful, hard, warm breast engorgement. She is formula-feeding. What intervention should the nurse recommend?

Initiate breastfeeding to relieve pressure
Apply warm compresses and manually express milk
Wear a supportive bra, apply ice packs, and avoid nipple stimulation (Correct answer)
Administer a diuretic as ordered

Correct answer: Wear a supportive bra, apply ice packs, and avoid nipple stimulation

For non-breastfeeding clients, engorgement is managed by wearing a snug bra, applying cold compresses, and avoiding stimulation that triggers further milk production.

Question 136: A patient requires induction of labor with a cervical ripening agent. Misoprostol (Cytotec) 25 mcg is placed vaginally. Which finding requires the nurse to withhold the next dose?

Cervical dilation of 2 cm from 1 cm
Contractions every 2 minutes lasting 90 seconds with incomplete uterine relaxation (Correct answer)
Contractions every 8 minutes lasting 30 seconds
Baseline fetal heart rate of 145 bpm with moderate variability

Correct answer: Contractions every 2 minutes lasting 90 seconds with incomplete uterine relaxation

Uterine tachysystole with inadequate uterine relaxation indicates excessive response to misoprostol; subsequent doses must be withheld to prevent fetal hypoxia from placental insufficiency.

Question 137: A postpartum patient requires methylergonovine (Methergine) for uterine atony after vaginal delivery. Which condition is an absolute contraindication?

Hypertension with blood pressure of 160/110 mmHg (Correct answer)
Breastfeeding
Gestational age less than 37 weeks
Previous cesarean delivery

Correct answer: Hypertension with blood pressure of 160/110 mmHg

Methylergonovine causes vasoconstriction and is absolutely contraindicated in hypertensive patients because it can precipitate severe hypertension, stroke, or myocardial infarction.

Question 138: A breastfeeding mother reports white, shiny, painful nipples between feedings with a shooting pain into the breast. What condition should the nurse suspect?

Mastitis
Nipple and breast candidiasis (thrush) (Correct answer)
Normal postpartum engorgement
Raynaud's phenomenon of the nipple

Correct answer: Nipple and breast candidiasis (thrush)

Candidal nipple infection presents with shiny, white, painful nipples and deep, shooting breast pain between feedings; both mother and infant (oral thrush) require simultaneous antifungal treatment.

Question 139: A client with postpartum depression asks the nurse, 'Why does this happen to me?' Which response is most accurate?

It results from a combination of hormonal changes, sleep deprivation, and psychosocial stressors. (Correct answer)
PPD is a sign that you were not emotionally ready for motherhood.
Postpartum depression is caused solely by a lack of willpower or motivation.
It is caused by failure to bond with the baby immediately after birth.

Correct answer: It results from a combination of hormonal changes, sleep deprivation, and psychosocial stressors.

PPD is multifactorial, involving hormonal shifts (particularly estrogen and progesterone), sleep deprivation, social support deficits, and individual psychological vulnerabilities.

Question 140: Erythromycin ophthalmic ointment is administered to newborns to prevent which infection?

Neonatal herpes simplex eye infection
Group B Streptococcal conjunctivitis
Ophthalmia neonatorum caused by Neisseria gonorrhoeae and Chlamydia trachomatis (Correct answer)
Retinopathy of prematurity

Correct answer: Ophthalmia neonatorum caused by Neisseria gonorrhoeae and Chlamydia trachomatis

Erythromycin 0.5% ophthalmic ointment is required by law in most US states to prevent ophthalmia neonatorum, a potentially blinding infection transmitted during vaginal delivery.

Question 141: A nurse is preparing to give a newborn the first bath. Which condition must be met before the bath is given?

The newborn must be at least 12 hours old
The newborn must have passed the first meconium stool
The provider must write a bath order
The newborn's temperature must be stable at 36.5°C or above for at least 1 hour (Correct answer)

Correct answer: The newborn's temperature must be stable at 36.5°C or above for at least 1 hour

Bathing is delayed until the newborn's temperature is stable (≥36.5°C) to prevent cold stress and hypothermia; WHO recommends delaying the first bath ≥24 hours.

Question 142: A client on postpartum day 1 is crying and states she feels overwhelmed and irritable. Her assessment is otherwise normal. How should the nurse interpret this?

Normal postpartum blues related to hormonal shifts (Correct answer)
Early sign of postpartum psychosis
Probable postpartum depression requiring psychiatric referral
Grief response requiring social work consult

Correct answer: Normal postpartum blues related to hormonal shifts

Postpartum blues affect up to 80% of new mothers within the first few days due to rapid estrogen and progesterone decline; they resolve within 2 weeks without treatment.

Question 143: A nurse is preparing to administer vitamin K (phytonadione) to a newborn. Which site and route are correct?

Vastus lateralis, intramuscular (Correct answer)
Deltoid muscle, intramuscular
Intravenous via umbilical vein
Subcutaneous tissue of the abdomen

Correct answer: Vastus lateralis, intramuscular

Vitamin K is administered intramuscularly into the vastus lateralis (anterolateral thigh) muscle in newborns, as it is the preferred IM site.

Question 144: A preterm newborn at 28 weeks is receiving total parenteral nutrition (TPN). Which complication should the nurse monitor for most closely?

Metabolic alkalosis from amino acids
Hyperglycemia and catheter-related bloodstream infection (CRBSI) (Correct answer)
Iron overload from TPN additives
Hypoglycemia caused by excess dextrose

Correct answer: Hyperglycemia and catheter-related bloodstream infection (CRBSI)

Preterm neonates on TPN are at high risk for hyperglycemia (immature glucose regulation) and CRBSI from central line use; blood glucose and infection signs must be monitored closely.

Question 145: Which reflex is assessed by stroking the lateral aspect of the sole of the newborn's foot from heel to toe, resulting in dorsiflexion of the big toe and fanning of other toes?

Stepping reflex
Rooting reflex
Babinski reflex (Correct answer)
Moro reflex

Correct answer: Babinski reflex

The Babinski reflex (plantar reflex) is elicited by stroking the lateral sole; dorsiflexion of the great toe and toe fanning is a normal finding in newborns due to immature corticospinal tracts.

Question 146: What does an acceleration in the fetal heart rate tracing typically indicate?

Fetal well-being and adequate oxygenation (Correct answer)
Umbilical cord compression
Fetal hypoxia
Uterine tachysystole

Correct answer: Fetal well-being and adequate oxygenation

Accelerations (≥15 bpm above baseline for ≥15 seconds) are a reassuring sign indicating adequate fetal oxygenation and neurological integrity.

Question 147: Which newborn vital sign range is considered normal for a term newborn?

Heart rate 80–100 bpm, respiratory rate 20–30 breaths/min, temperature 37.5–38.5°C
Heart rate 160–200 bpm, respiratory rate 60–80 breaths/min, temperature 36.0–36.5°C
Heart rate 110–160 bpm, respiratory rate 30–60 breaths/min, temperature 36.5–37.5°C (Correct answer)
Heart rate 100–120 bpm, respiratory rate 40–50 breaths/min, temperature 37.0–38.0°C

Correct answer: Heart rate 110–160 bpm, respiratory rate 30–60 breaths/min, temperature 36.5–37.5°C

Normal newborn vital signs: HR 110–160 bpm, RR 30–60 breaths/min, and temperature 36.5–37.5°C axillary.

Question 148: A nurse is caring for a neonate with intraventricular hemorrhage (IVH). Which behavior change would the nurse most likely observe?

Decreased oxygen requirements
Hyperglycemia and polyuria
Bulging anterior fontanel, apnea, and seizures (Correct answer)
Excessive activity and crying

Correct answer: Bulging anterior fontanel, apnea, and seizures

IVH in preterm infants presents with bulging fontanel due to increased intracranial pressure, along with apneic episodes and seizure activity reflecting neurological compromise.

Question 149: A newborn is placed under phototherapy for hyperbilirubinemia. Which nursing intervention is MOST important during phototherapy?

Position the infant prone for maximum light exposure
Cover the eyes with opaque shields to protect from retinal damage (Correct answer)
Keep the infant bundled warmly to maintain temperature
Restrict feedings to 3-hour intervals only

Correct answer: Cover the eyes with opaque shields to protect from retinal damage

Eye shields must be applied during phototherapy to protect the newborn's retinas and corneas from intense light exposure that can cause permanent damage.

Question 150: To conduct a foundational assessment on a postpartum patients, a nurse is getting ready. Which of the following is the first nursing intervention in this assessment?

Ask the client to turn on her side.
Ask the client to lie flat on her back with the knees and legs flat and straight.
Massage the fundus gently before determining the level of the fundus.
Ask the mother to urinate and empty her bladder. (Correct answer)

Correct answer: Ask the mother to urinate and empty her bladder.

The nurse should ask the mother to empty her bladder before beginning the fundal assessment in order to perform it accurately. The six to eight weeks following delivery, or from the moment of birth, are included in the postpartum recovery period. As the mother's body returns to pre-pregnancy conditions, this is a time of healing and renewal.

Question 151: The nurse is assessing a 24-hour-old newborn and observes yellow discoloration of the skin and sclera. The total bilirubin level is 6 mg/dL. How should the nurse interpret this finding?

Pathological jaundice requiring immediate phototherapy
Sign of ABO incompatibility requiring exchange transfusion
Physiological jaundice, expected at this age (Correct answer)
Hepatic failure requiring further investigation

Correct answer: Physiological jaundice, expected at this age

Physiological jaundice typically appears after 24 hours of life with bilirubin peaking at 3–5 days, and a level of 6 mg/dL at 24 hours is within physiological range for a term infant.

Question 152: Which pain management intervention is evidence-based for use during painful newborn procedures such as heel sticks?

Topical EMLA cream applied 60 minutes before
Oral sucrose solution given 2 minutes before the procedure (Correct answer)
No intervention is needed as newborns do not feel pain
IV morphine administration

Correct answer: Oral sucrose solution given 2 minutes before the procedure

Oral sucrose (24% solution, 0.5–2 mL) administered 2 minutes before painful procedures activates endogenous opioid pathways and reduces behavioral pain responses in newborns.

Question 153: A neonate is showing signs of neonatal abstinence syndrome (NAS). Which set of findings is consistent with this diagnosis?

Hypotonia, lethargy, bradycardia, hypothermia
Jaundice, hepatomegaly, petechiae
Hypoglycemia, central cyanosis, weak suck
High-pitched cry, tremors, poor feeding, diarrhea (Correct answer)

Correct answer: High-pitched cry, tremors, poor feeding, diarrhea

NAS results from opioid or other substance withdrawal and is characterized by high-pitched cry, irritability, tremors, poor feeding, and GI disturbances such as diarrhea.

Question 154: A newborn has a cephalohematoma identified on assessment. Which statement about cephalohematoma is accurate?

It is caused by molding of the skull during labor
It crosses the suture lines of the skull
It resolves within 24 hours after delivery
It is a collection of blood between the periosteum and skull bone limited by suture lines (Correct answer)

Correct answer: It is a collection of blood between the periosteum and skull bone limited by suture lines

A cephalohematoma is a subperiosteal hemorrhage confined by suture lines that does not cross sutures, distinguishing it from caput succedaneum which does cross suture lines.

Question 155: When assessing the anterior fontanel of a newborn, which finding is abnormal?

Soft and flat fontanel
Bulging and tense fontanel in a quiet, non-crying infant (Correct answer)
Fontanel that slightly bulges when the infant cries
Diamond-shaped fontanel measuring 2 × 2 cm

Correct answer: Bulging and tense fontanel in a quiet, non-crying infant

A bulging, tense fontanel in a quiet infant suggests increased intracranial pressure due to conditions such as hydrocephalus, meningitis, or intracranial hemorrhage.

Question 156: A patient at 34 weeks gestation presents with a blood pressure of 158/106 mmHg, severe headache, visual disturbances, and 3+ proteinuria. What condition does this represent?

Severe feature preeclampsia (Correct answer)
Chronic hypertension
HELLP syndrome
Gestational hypertension

Correct answer: Severe feature preeclampsia

Blood pressure ≥160/110 mmHg with severe symptoms (headache, visual changes) and significant proteinuria meets criteria for preeclampsia with severe features requiring urgent intervention.

Question 157: Which finding during a postpartum home visit requires the nurse to immediately contact the healthcare provider?

The mother reports feeling tired and overwhelmed by her new role
The mother expresses concern about her ability to maintain milk supply
The mother states she has thoughts of harming herself or the infant (Correct answer)
The mother cries when discussing her birth experience

Correct answer: The mother states she has thoughts of harming herself or the infant

Suicidal ideation or thoughts of harming the infant constitute a psychiatric emergency requiring immediate provider notification and intervention.

Question 158: The nurse is assessing fetal heart rate monitoring strips. Which characteristic of fetal heart rate variability is MOST reassuring of fetal well-being?

Moderate variability (6–25 bpm) (Correct answer)
Minimal variability (less than 5 bpm)
Absent variability
Marked variability (greater than 25 bpm)

Correct answer: Moderate variability (6–25 bpm)

Moderate FHR variability (6–25 bpm) reflects an intact, well-oxygenated autonomic nervous system and is the most reassuring sign of fetal well-being.

Question 159: A nurse assesses a newborn at 1 minute and assigns an Apgar score. The infant has a heart rate of 98 bpm, weak cry, some flexion of extremities, grimace to stimulation, and a pink body with blue extremities. What is the Apgar score?

8
6 (Correct answer)
5
7

Correct answer: 6

HR <100 = 1, weak cry (slow, irregular respirations) = 1, some flexion = 1, grimace = 1, pink body/blue extremities (acrocyanosis) = 1, totaling 6.

Question 160: A nurse is monitoring a client receiving epidural analgesia in labor. Which complication should the nurse assess for most closely?

Fetal tachycardia
Uterine hyperstimulation
Maternal hypotension (Correct answer)
Maternal hyperglycemia

Correct answer: Maternal hypotension

Epidural analgesia causes vasodilation, which can precipitate maternal hypotension, reducing uteroplacental blood flow and causing fetal heart rate decelerations.

Question 161: A pregnant patient has a hemoglobin of 9.2 g/dL and is diagnosed with iron-deficiency anemia. Which instruction about iron supplementation is most important?

Take iron with orange juice or vitamin C to enhance absorption (Correct answer)
Take iron with meals only to prevent nausea
Take iron with calcium supplements to improve tolerance
Take iron with milk to enhance absorption

Correct answer: Take iron with orange juice or vitamin C to enhance absorption

Vitamin C (ascorbic acid) enhances the absorption of non-heme iron by converting ferric iron to the more absorbable ferrous form; dairy products and calcium decrease iron absorption.

Question 162: The nurse is monitoring a patient receiving oxytocin for labor augmentation. Which finding requires the nurse to immediately stop the infusion?

Contractions every 3 minutes lasting 45 seconds
Fetal heart rate baseline of 140 bpm
Uterine hyperstimulation with 6 contractions in 10 minutes (Correct answer)
Cervical dilation progressing 1 cm per hour

Correct answer: Uterine hyperstimulation with 6 contractions in 10 minutes

Uterine tachysystole (more than 5 contractions in 10 minutes) from oxytocin requires immediate cessation of the infusion to prevent fetal hypoxia.

Question 163: A nurse is caring for a client with severe preeclampsia receiving magnesium sulfate. Which assessment finding indicates magnesium toxicity?

Respiratory rate of 10 breaths per minute and absent deep tendon reflexes (Correct answer)
Blood pressure of 150/95 mmHg
Serum magnesium level of 5 mEq/L
Urinary output of 35 mL/hr

Correct answer: Respiratory rate of 10 breaths per minute and absent deep tendon reflexes

Magnesium toxicity causes respiratory depression (<12 breaths/min) and loss of deep tendon reflexes (DTRs); the antidote is calcium gluconate.

Question 164: A nurse is assessing gestational age using the Ballard score. Which neuromuscular maturity finding is expected in a full-term newborn (38–40 weeks)?

Arm recoil with brisk return to flexion (Correct answer)
Scarf sign with elbow easily past midline
Popliteal angle of 180 degrees
Arms remaining extended after release

Correct answer: Arm recoil with brisk return to flexion

Full-term newborns demonstrate active flexion tone, so when the arm is extended and released, it quickly returns to the flexed position (brisk arm recoil).

Question 165: A day one PP patient's lochia is being evaluated by the nurse. The nurse remarks that the lochia is crimson and smells bad. This evaluation finding is determined to be by the nurse to be:

Indicates the presence of infection. (Correct answer)
Normal
Indicates the need for increasing oral fluids.
Indicates the need for increasing ambulation.

Correct answer: Indicates the presence of infection.

For the first one to three days after birth, the discharge known as lochia is red and gradually lessens in volume. It is abnormal to encounter lochia that smells bad or is purulent because these symptoms typically imply infection. Large chunks of tissue, blood clots, an unpleasant odor, or the absence of lochia could all be symptoms of infection.

Question 166: Which site is preferred for vitamin K injection in a newborn?

Dorsal gluteal site
Vastus lateralis (anterolateral thigh) (Correct answer)
Deltoid muscle
Gluteus maximus

Correct answer: Vastus lateralis (anterolateral thigh)

The vastus lateralis (anterolateral thigh) is the preferred IM injection site for newborns because it has the largest muscle mass at this age and avoids critical nerves and vessels.

Question 167: A patient is admitted with suspected placenta previa at 32 weeks gestation. She is experiencing bright red, painless vaginal bleeding. Which assessment is CONTRAINDICATED?

External fetal heart rate monitoring
Digital vaginal examination (Correct answer)
IV access placement
Abdominal ultrasound

Correct answer: Digital vaginal examination

Digital vaginal examination is absolutely contraindicated in placenta previa because it can disrupt the placenta and cause catastrophic hemorrhage; diagnosis is confirmed by ultrasound.

Question 168: A client at 36 weeks gestation presents with sudden, severe abdominal pain, a rigid board-like abdomen, and dark red vaginal bleeding. Fetal heart tones are difficult to auscultate. The nurse suspects:

Placenta previa with active hemorrhage
Preterm labor with bloody show
Uterine rupture from previous cesarean scar
Severe abruptio placentae (Correct answer)

Correct answer: Severe abruptio placentae

Sudden severe abdominal pain, board-like uterine rigidity, dark red vaginal bleeding, and compromised fetal heart tones are classic signs of severe abruptio placentae.

Question 169: A newborn shows signs of hypocalcemia at 24 hours of life. Which risk factor is most directly associated with early neonatal hypocalcemia?

Maternal diabetes mellitus (Correct answer)
Postmature gestational age
Maternal hypothyroidism
Maternal hypothyroidism

Correct answer: Maternal diabetes mellitus

Infants of diabetic mothers are at increased risk for hypocalcemia because maternal hyperglycemia suppresses fetal parathyroid function, and neonatal calcium regulation is impaired after birth.

Question 170: The nurse is assessing a patient in labor and notes the fetal heart rate drops to 90 bpm following each contraction and gradually returns to baseline. This pattern is described as:

Early decelerations
Late decelerations (Correct answer)
Sinusoidal pattern
Variable decelerations

Correct answer: Late decelerations

Late decelerations begin after the uterine contraction peak and return to baseline after the contraction ends, indicating uteroplacental insufficiency.

Question 171: A newborn is born at 39 weeks to a mother with Type 1 diabetes. Which complication is the newborn at highest risk for in the first hours of life?

Hyperglycemia secondary to maternal insulin resistance
Respiratory alkalosis from rapid breathing
Polycythemia leading to hyperviscosity syndrome
Hypoglycemia due to fetal hyperinsulinemia (Correct answer)

Correct answer: Hypoglycemia due to fetal hyperinsulinemia

Infants of diabetic mothers develop hyperinsulinemia in utero; when maternal glucose is removed at birth, high insulin levels cause neonatal hypoglycemia.

Question 172: A nurse is assessing lochia on a postpartum client at day 5. Which characteristic is expected?

Yellow-white (alba)
Pink to brown (serosa) (Correct answer)
Dark red with foul odor
Bright red with clots

Correct answer: Pink to brown (serosa)

Lochia serosa, which is pinkish-brown and watery, is the normal discharge expected between days 4–10 postpartum.

Question 173: A breastfed newborn at 5 days of life has 7 wet diapers and 3 yellow, seedy stools per day. The mother is concerned about the frequency of stools. What should the nurse tell her?

This is a normal stool pattern for a breastfed newborn and indicates adequate milk intake (Correct answer)
The newborn likely has diarrhea and should be seen by the provider
Reduce the frequency of breastfeeding sessions
Formula supplementation is needed to firm up the stools

Correct answer: This is a normal stool pattern for a breastfed newborn and indicates adequate milk intake

Breastfed infants normally have frequent, loose, yellow, seedy stools — 3 or more per day by day 4 — and multiple wet diapers indicating adequate feeding.

Question 174: A nurse notes meconium-stained amniotic fluid at rupture of membranes. What is the priority nursing action?

Prepare for immediate cesarean delivery
Increase IV fluid rate to dilute the amniotic fluid
Apply continuous electronic fetal monitoring and notify the provider (Correct answer)
Reassure the client that this is a normal finding

Correct answer: Apply continuous electronic fetal monitoring and notify the provider

Meconium-stained fluid may indicate fetal distress and increases the risk for meconium aspiration syndrome; continuous FHR monitoring and provider notification are the priority.

Question 175: Which normal newborn reflex disappears by approximately 3–4 months of age and indicates intact neurological function at birth?

Rooting reflex
Babinski reflex
Moro (startle) reflex (Correct answer)
Plantar grasp reflex

Correct answer: Moro (startle) reflex

The Moro reflex (symmetric arm extension/abduction followed by adduction) is present at birth and normally disappears by 3–4 months as cortical control matures.

Question 176: A breastfeeding mother is prescribed codeine for postpartum pain. Why is this medication of particular concern for her breastfed infant?

Codeine is not absorbed through breast milk
Codeine causes maternal hypotension affecting milk production
Ultra-rapid metabolizers convert codeine to morphine at higher rates, risking neonatal opioid toxicity (Correct answer)
Codeine increases neonatal alertness and feeding difficulty

Correct answer: Ultra-rapid metabolizers convert codeine to morphine at higher rates, risking neonatal opioid toxicity

Ultra-rapid CYP2D6 metabolizers convert codeine to morphine faster than normal, leading to dangerously high morphine levels in breast milk that can cause neonatal respiratory depression.

RNC-MNN: Maternal Newborn Nursing Certification Exam

The RNC-MNN is an NCC-administered certification exam for registered nurses specializing in maternal and newborn care, covering pregnancy complications, postpartum assessment and complications, and newborn assessment and management.

Questions

35 min

Time Limit

70%

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