Maternal Newborn Nursing Test Maternity Nursing (OB Maternal & Newborn) 2 — Questions and Answers
Question 1: 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?
- Administer oxytocin immediately
- Assist the client to empty her bladder (Correct answer)
- Massage the fundus vigorously
- Notify the physician of uterine atony
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 2: Which finding in a newborn at 24 hours of life requires immediate reporting to the provider?
- Acrocyanosis of hands and feet
- Respiratory rate of 68 breaths/min at rest (Correct answer)
- Caput succedaneum over the occiput
- Positive Babinski reflex
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 3: A gravida 3, para 2 client is at 38 weeks gestation and reports decreased fetal movement. The nurse performs a nonstress test (NST). Which result is considered REACTIVE?
- Two accelerations of 15 bpm lasting 15 seconds in 20 minutes (Correct answer)
- One acceleration of 10 bpm lasting 10 seconds in 40 minutes
- Absence of fetal movement with no accelerations
- Variable decelerations with each fetal movement
Correct answer: Two accelerations of 15 bpm lasting 15 seconds in 20 minutes
A reactive NST requires at least two fetal heart rate accelerations of ≥15 bpm above baseline, each lasting ≥15 seconds, within a 20-minute period.
Question 4: 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?
- Apply fundal pressure to expedite delivery
- Double-clamp and cut the cord before delivery (Correct answer)
- Perform an emergency cesarean section
- Instruct the client to push harder with the next contraction
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 5: A nurse is caring for a client receiving magnesium sulfate for severe preeclampsia. Which assessment finding requires the nurse to withhold the next dose?
- Deep tendon reflexes 2+
- Urine output of 35 mL/hr
- Respiratory rate of 10 breaths/min (Correct answer)
- Blood pressure 158/104 mmHg
Correct answer: Respiratory rate of 10 breaths/min
A respiratory rate below 12 breaths/min is a sign of magnesium toxicity and the infusion must be stopped immediately.
Question 6: A newborn's Apgar score at 1 minute is assessed: heart rate 98, weak cry, some flexion, grimace only, body pink with blue extremities. What is the total Apgar score?
Correct answer: 6
HR <100=1, weak cry=1, some flexion=1, grimace=1, acrocyanosis=1 totals 6, indicating the newborn needs some resuscitative support.
Question 7: A breastfeeding mother at 48 hours postpartum reports her breasts are hard, warm, and painful. Milk is not flowing easily. What is the most appropriate nursing intervention?
- Instruct her to stop breastfeeding and apply ice packs
- Encourage frequent feedings and apply warm compresses before nursing (Correct answer)
- Administer antibiotics for mastitis
- Recommend formula supplementation until engorgement resolves
Correct answer: Encourage frequent feedings and apply warm compresses before nursing
Engorgement is managed by frequent breastfeeding and applying warmth before feedings to promote letdown and milk flow.
