Maternal Newborn Nursing Test Maternity Nursing (OB Maternal & Newborn) 4 — Questions and Answers
Question 1: A client at 41 weeks gestation undergoes a biophysical profile (BPP). A score of 6 out of 10 is obtained. What is the nurse's understanding of this result?
- Normal — no further testing needed this week
- Equivocal — further evaluation or delivery may be indicated (Correct answer)
- Severely abnormal — immediate cesarean delivery is required
- Reactive NST component negates the other abnormal findings
Correct answer: Equivocal — further evaluation or delivery may be indicated
A BPP score of 6/10 is equivocal and requires further evaluation, possible repeat testing, or consideration of delivery depending on gestational age.
Question 2: A nurse is teaching a client about signs of preterm labor. Which symptom should the client report immediately?
- Braxton Hicks contractions every 20–30 minutes that stop with rest
- A low backache that comes and goes every 10 minutes at 32 weeks (Correct answer)
- Increased white creamy vaginal discharge at 36 weeks
- Urinary frequency without burning at 28 weeks
Correct answer: A low backache that comes and goes every 10 minutes at 32 weeks
Regular low backaches occurring every 10 minutes at 32 weeks may indicate preterm labor contractions and require immediate medical evaluation.
Question 3: Which newborn reflex disappears by 3–4 months of age and, if still present after 6 months, may indicate neurological damage?
- Stepping reflex
- Moro reflex (Correct answer)
- Rooting reflex
- Palmar grasp reflex
Correct answer: Moro reflex
The Moro (startle) reflex normally disappears by 3–4 months; persistence beyond 6 months can indicate central nervous system dysfunction.
Question 4: A nurse is preparing to administer vitamin K (phytonadione) to a newborn. Which site and route are correct?
- Deltoid muscle, intramuscular
- Vastus lateralis, intramuscular (Correct answer)
- Subcutaneous tissue of the abdomen
- Intravenous via umbilical vein
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 5: 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
- Severe abruptio placentae (Correct answer)
- Uterine rupture from previous cesarean scar
- Preterm labor with bloody show
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 6: A nurse is assessing lochia in a client on postpartum day 5. Which finding is expected?
- Lochia rubra — bright red with clots
- Lochia serosa — pinkish-brown, serosanguineous discharge (Correct answer)
- Lochia alba — white-yellow creamy discharge
- Heavy bright red flow soaking one pad per hour
Correct answer: Lochia serosa — pinkish-brown, serosanguineous discharge
By postpartum day 3–10, lochia transitions from rubra to serosa, which is pinkish-brown and serosanguineous in character.
Question 7: A pregnant client at 28 weeks is Rh-negative with an Rh-positive partner. Her indirect Coombs test is negative. Which intervention is indicated?
- No treatment is needed until delivery
- Administer Rho(D) immune globulin (RhoGAM) now (Correct answer)
- Schedule an immediate intrauterine blood transfusion
- Perform an amniocentesis to test fetal blood type
Correct answer: Administer Rho(D) immune globulin (RhoGAM) now
RhoGAM is given at 28 weeks to Rh-negative, unsensitized mothers to prevent isoimmunization in the current and future pregnancies.
