Download Maternal Newborn Nursing Practice Exam 2026 with Rationales and more Exams Nursing in PDF only on Docsity!
Maternal-Newborn Nursing Practice Exam | Updated 2026 Complete Study Guide |
Verified Questions with Detailed Rationales on Antepartum Care, High-Risk
Pregnancy Conditions, Intrapartum Labor & Delivery Stages, Fetal Heart Rate
Monitoring & Interpretation, Postpartum Care & Complications, Newborn
Assessment & Reflexes, Medication Administration, Breastfeeding & Lactation
Support, and Evidence-Based Nursing Interventions for Exam Success
Question 1: A nurse is assessing a newborn at 24 hours of age. Which finding requires immediate intervention? A. Acrocyanosis B. Respiratory rate of 50 breaths per minute C. Heart rate of 110 beats per minute while sleeping D. Subcostal retractions CORRECT ANSWER: D. Subcostal retractions Rationale: Subcostal retractions are a sign of respiratory distress and require immediate assessment and intervention. Acrocyanosis (bluish discoloration of hands and feet) is normal in the first 24-48 hours. A respiratory rate of 30-60 breaths per minute is within the normal range for a newborn. A heart rate of 110-160 beats per minute is normal, though it may drop slightly during sleep. Question 2: A postpartum client is receiving oxytocin for uterine atony. Which assessment finding indicates the medication is effective? A. Blood pressure increases from 110/70 to 130/80 mmHg B. Fundus becomes firm and midline C. Lochia rubra increases in amount D. Client reports decreased afterpains CORRECT ANSWER: B. Fundus becomes firm and midline Rationale: Oxytocin stimulates uterine contractions, which should result in a firm, well- contracted fundus positioned in the midline. This helps prevent hemorrhage. An increase in blood pressure is not the primary indicator of effectiveness. Increased lochia would indicate continued bleeding, suggesting ineffectiveness. Afterpains may actually increase as the uterus contracts more strongly. Question 3: A pregnant client at 32 weeks gestation reports severe headache, visual disturbances, and epigastric pain. Her blood pressure is 160/110 mmHg. What is the priority nursing action? A. Administer oral acetaminophen for headache B. Place the client in a dark, quiet room C. Notify the healthcare provider immediately D. Assess deep tendon reflexes CORRECT ANSWER: C. Notify the healthcare provider immediately
Rationale: These symptoms indicate severe preeclampsia, which is a medical emergency requiring immediate provider notification for potential delivery or magnesium sulfate therapy. While placing the client in a quiet environment and assessing reflexes are important, they do not take precedence over notifying the provider. Acetaminophen does not address the underlying hypertensive crisis. Question 4: A nurse is teaching a new mother about breastfeeding positions. Which statement by the mother indicates understanding? A. "I should hold my baby's head firmly against my breast." B. "My baby's nose should be aligned with my nipple before latching." C. "I need to push my breast into my baby's mouth to ensure a good latch." D. "My baby only needs to have the nipple in their mouth, not the areola." CORRECT ANSWER: B. My baby's nose should be aligned with my nipple before latching. Rationale: Aligning the baby's nose with the nipple encourages the baby to tilt their head back slightly and open wide, facilitating a deep latch that includes both the nipple and a large portion of the areola. Holding the head firmly can interfere with the baby's ability to adjust positioning. Pushing the breast into the mouth can cause shallow latching. The baby must take in the areola, not just the nipple, to prevent nipple trauma and ensure adequate milk transfer. Question 5: A newborn is diagnosed with hyperbilirubinemia. Which intervention is most appropriate for phototherapy? A. Apply lotion to the skin before starting treatment B. Cover the newborn's eyes with opaque patches C. Dress the newborn in a diaper and lightweight shirt D. Turn off the lights when feeding the newborn CORRECT ANSWER: B. Cover the newborn's eyes with opaque patches Rationale: Eye protection is essential during phototherapy to prevent retinal damage from the bright lights. Lotions should not be applied as they can absorb heat and cause burns or block light penetration. The newborn should be undressed except for a diaper to maximize skin exposure to light. Phototherapy lights should remain on continuously; brief interruptions for feeding are acceptable but turning them off defeats the purpose of continuous treatment. Question 6: A postpartum client is experiencing heavy vaginal bleeding with large clots two hours after delivery. The fundus is boggy. What is the initial nursing intervention? A. Insert an indwelling urinary catheter B. Perform fundal massage C. Administer methylergonovine IM D. Prepare for emergency hysterectomy
Rationale: Infants of diabetic mothers are at high risk for hypoglycemia due to fetal hyperinsulinemia in response to maternal hyperglycemia. After birth, the glucose supply is interrupted, but insulin levels remain high, causing rapid glucose depletion. Post-term infants are more at risk for meconium aspiration and macrosomia. Cesarean delivery and high Apgar scores are not specific risk factors for hypoglycemia. Question 10: A postpartum client reports pain in her right calf. The area is warm, red, and swollen. What is the priority nursing action? A. Massage the affected area to improve circulation B. Apply warm compresses to the calf C. Notify the healthcare provider immediately D. Encourage ambulation to prevent clot propagation CORRECT ANSWER: C. Notify the healthcare provider immediately Rationale: These signs suggest deep vein thrombosis (DVT), a serious postpartum complication. The provider must be notified immediately for diagnostic testing and anticoagulation therapy. Massaging the area is contraindicated as it may dislodge the clot, causing a pulmonary embolism. Warm compresses and ambulation are not appropriate until DVT is ruled out or treated. Question 11: A nurse is preparing to administer vitamin K to a newborn. Which statement explains the rationale for this intervention? A. "It prevents infection by boosting the immune system." B. "It promotes bone growth and development." C. "It prevents hemorrhagic disease by aiding blood clotting." D. "It enhances bilirubin breakdown and prevents jaundice." CORRECT ANSWER: C. It prevents hemorrhagic disease by aiding blood clotting. Rationale: Newborns have low vitamin K stores because it does not cross the placenta well and their sterile intestines lack bacteria to synthesize it. Vitamin K is essential for producing clotting factors II, VII, IX, and X. Administration prevents hemorrhagic disease of the newborn. It does not boost immunity, promote bone growth (that is vitamin D), or affect bilirubin metabolism. Question 12: A client in labor requests an epidural anesthesia. Which assessment finding is a contraindication? A. Platelet count of 150,000/mm³ B. Blood pressure of 110/70 mmHg C. Temperature of 100.4°F (38°C) D. Hemoglobin of 12 g/dL CORRECT ANSWER: C. Temperature of 100.4°F (38°C) Rationale: Maternal fever may indicate chorioamnionitis or systemic infection, which are contraindications for epidural placement due to the risk of introducing infection into
the epidural space. A platelet count of 150,000/mm³ is within normal limits (normal is 150,000-400,000/mm³). Normal blood pressure and hemoglobin levels are not contraindications. Question 13: A nurse is teaching a pregnant client about warning signs during pregnancy. Which symptom should the client report immediately? A. Mild ankle edema at the end of the day B. Occasional heartburn after meals C. Vaginal bleeding at any gestational age D. Increased frequency of urination CORRECT ANSWER: C. Vaginal bleeding at any gestational age Rationale: Vaginal bleeding during pregnancy is never normal and requires immediate evaluation to rule out complications such as placenta previa, placental abruption, or miscarriage. Mild ankle edema, occasional heartburn, and urinary frequency are common discomforts of pregnancy and are not emergencies unless severe or accompanied by other symptoms. Question 14: A newborn exhibits a positive Ortolani sign during hip assessment. What does this finding indicate? A. Normal hip development B. Developmental dysplasia of the hip C. Fractured femur D. Muscle spasticity CORRECT ANSWER: B. Developmental dysplasia of the hip Rationale: A positive Ortolani sign (a click or clunk felt when the hip is abducted and lifted forward) indicates that a dislocated femoral head is being reduced into the acetabulum, suggesting developmental dysplasia of the hip (DDH). This requires further evaluation and possibly treatment with a Pavlik harness. It is not a normal finding and does not indicate fracture or spasticity. Question 15: A postpartum client is experiencing breast engorgement. Which intervention should the nurse recommend? A. Apply ice packs between feedings B. Limit fluid intake to reduce milk production C. Avoid breastfeeding to rest the breasts D. Use tight-fitting bras for support CORRECT ANSWER: A. Apply ice packs between feedings Rationale: Ice packs applied between feedings help reduce swelling and pain associated with engorgement. Frequent breastfeeding or pumping is recommended to relieve engorgement, not avoidance. Adequate fluid intake should be maintained.
6 to 8 shows the newborn is responding well to interventions and adapting to extrauterine life. Scores of 0-3 indicate critical condition requiring extensive resuscitation. Question 19: A client in the latent phase of labor is experiencing anxiety. Which nursing intervention is most appropriate? A. Administer sedative medication immediately B. Encourage the partner to leave the room C. Provide reassurance and teach relaxation techniques D. Prepare for immediate cesarean delivery CORRECT ANSWER: C. Provide reassurance and teach relaxation techniques Rationale: Anxiety is common in early labor. Reassurance, emotional support, and teaching relaxation techniques such as breathing exercises help the client cope. Sedatives are generally avoided as they can cross the placenta and depress the fetus. Partner support is beneficial and should be encouraged. Cesarean delivery is not indicated for anxiety alone. Question 20: A nurse is caring for a postpartum client who had a cesarean birth. Which intervention promotes optimal recovery? A. Keep the client on strict bed rest for 48 hours B. Encourage early ambulation within 8-12 hours C. Restrict fluid intake to prevent nausea D. Delay bonding activities until day three CORRECT ANSWER: B. Encourage early ambulation within 8-12 hours Rationale: Early ambulation after cesarean birth promotes circulation, prevents thromboembolism, stimulates bowel function, and enhances recovery. Prolonged bed rest increases the risk of complications. Adequate fluid intake is important for hydration and milk production. Bonding should begin immediately after birth when possible, not delayed. Question 21: A pregnant client at 36 weeks gestation reports a sudden gush of fluid from the vagina. What is the priority nursing action? A. Perform a vaginal examination to check dilation B. Assess the color and odor of the fluid C. Check the fetal heart rate D. Prepare the client for immediate delivery CORRECT ANSWER: C. Check the fetal heart rate Rationale: Rupture of membranes puts the fetus at risk for cord prolapse and infection. Assessing fetal heart rate is the priority to ensure fetal well-being. Vaginal examinations should be avoided until fetal presentation is confirmed to prevent cord prolapse if the head is not engaged. Assessing fluid characteristics is important but secondary to fetal
assessment. Immediate delivery is not always necessary unless there are complications. Question 22: A nurse is educating a new father about newborn safety. Which statement indicates a need for further teaching? A. "I will place my baby on their back to sleep." B. "I will use a firm mattress with a fitted sheet." C. "I will keep soft toys and pillows in the crib for comfort." D. "I will ensure the room temperature is comfortable, not too hot." CORRECT ANSWER: C. I will keep soft toys and pillows in the crib for comfort. Rationale: Soft toys, pillows, bumper pads, and loose bedding increase the risk of Sudden Infant Death Syndrome (SIDS) and suffocation. The crib should contain only a firm mattress with a fitted sheet. Back sleeping, firm mattresses, and appropriate room temperature are all correct safety measures. Question 23: A client experiences variable decelerations during labor. What is the most likely cause? A. Uteroplacental insufficiency B. Umbilical cord compression C. Fetal head compression D. Maternal hypotension CORRECT ANSWER: B. Umbilical cord compression Rationale: Variable decelerations are caused by umbilical cord compression, resulting in abrupt decreases in fetal heart rate that vary in timing and shape. Uteroplacental insufficiency causes late decelerations. Fetal head compression causes early decelerations. Maternal hypotension can contribute to late decelerations but is not the primary cause of variable decelerations. Question 24: A newborn is exhibiting signs of neonatal abstinence syndrome (NAS). Which intervention is appropriate? A. Swaddle tightly and minimize environmental stimuli B. Stimulate the newborn frequently to maintain alertness C. Place the newborn in a brightly lit nursery D. Feed every 4-6 hours on a strict schedule CORRECT ANSWER: A. Swaddle tightly and minimize environmental stimuli Rationale: Newborns with NAS are hypersensitive to stimuli. Swaddling provides containment and security, while minimizing noise, light, and handling reduces agitation and conserves energy. Frequent stimulation and bright lights exacerbate symptoms. Feeding should be on demand, often more frequently than every 4-6 hours, as these infants have increased metabolic needs and may have difficulty coordinating suck- swallow-breathe.
A. Present at birth B. Crosses suture lines C. Does not cross suture lines D. Resolves within 24 hours CORRECT ANSWER: C. Does not cross suture lines Rationale: Cephalohematoma is a subperiosteal hemorrhage that is confined by suture lines and does not cross them. It may appear several hours after birth and takes weeks to resolve. Caput succedaneum is edema of the scalp that crosses suture lines, is present at birth, and resolves within 24-48 hours. Question 29: A client in labor is 8 cm dilated and expresses an urge to push. What is the priority nursing action? A. Encourage the client to push with each contraction B. Instruct the client to pant or blow during contractions C. Prepare for immediate delivery in the current location D. Administer an epidural anesthesia CORRECT ANSWER: B. Instruct the client to pant or blow during contractions Rationale: At 8 cm dilation, the client is not fully dilated. Pushing before full dilation can cause cervical edema and tearing. Panting or blowing helps resist the urge to push until full dilation (10 cm) is achieved. Pushing should only begin at full dilation. Epidural administration at this stage may be too late and is not the priority. Question 30: A nurse is teaching a postpartum client about lochia. Which statement indicates understanding? A. "Lochia alba occurs during the first three days postpartum." B. "Lochia should have a foul odor." C. "Lochia rubra changes to serosa around day 3-4." D. "I should expect bright red bleeding for two weeks." CORRECT ANSWER: C. Lochia rubra changes to serosa around day 3-4. Rationale: Lochia rubra (red) lasts 1-3 days, then transitions to lochia serosa (pinkish- brown) around days 3-10, and finally to lochia alba (white-yellow) from days 10-28. A foul odor indicates infection. Bright red bleeding beyond the first few days or saturation of more than one pad per hour requires evaluation. Question 31: A pregnant client at 30 weeks gestation is diagnosed with placenta previa. Which instruction is most important? A. Engage in regular exercise to maintain fitness B. Report any vaginal bleeding immediately C. Perform daily vaginal self-examinations D. Plan for a vaginal delivery
CORRECT ANSWER: B. Report any vaginal bleeding immediately Rationale: Placenta previa involves placental implantation over or near the cervical os, causing painless vaginal bleeding. Any bleeding requires immediate evaluation. Sexual intercourse, vaginal examinations, and strenuous activity are contraindicated as they can provoke bleeding. Cesarean delivery is typically required for complete placenta previa. Question 32: A newborn is noted to have a heart murmur. Which additional finding suggests a congenital heart defect? A. Acrocyanosis B. Peripheral pulses + C. Cyanosis during crying D. Respiratory rate of 45 breaths per minute CORRECT ANSWER: C. Cyanosis during crying Rationale: Cyanosis, especially during exertion like crying, suggests inadequate oxygenation due to a cardiac defect. Acrocyanosis is normal in newborns. Strong peripheral pulses and a respiratory rate of 45 (within normal range of 30-60) are reassuring findings. Central cyanosis or cyanosis with activity warrants further cardiac evaluation. Question 33: A nurse is caring for a client with hyperemesis gravidarum. Which intervention is priority? A. Offer large meals three times daily B. Administer IV fluids and electrolytes C. Encourage spicy foods to stimulate appetite D. Maintain NPO status indefinitely CORRECT ANSWER: B. Administer IV fluids and electrolytes Rationale: Hyperemesis gravidarum causes severe nausea and vomiting leading to dehydration, electrolyte imbalances, and weight loss. IV fluid and electrolyte replacement is the priority to restore hydration and correct imbalances. Small, frequent bland meals are preferred over large meals. Spicy foods can worsen nausea. NPO status is temporary until vomiting is controlled, not indefinite. Question 34: A postpartum client is experiencing difficulty voiding six hours after delivery. Which intervention should the nurse implement first? A. Insert an indwelling urinary catheter B. Pour warm water over the perineum C. Administer a diuretic medication D. Restrict fluid intake CORRECT ANSWER: B. Pour warm water over the perineum
C. Sit on hard surfaces to promote circulation D. Avoid perineal hygiene to prevent irritation CORRECT ANSWER: A. Apply ice packs to the perineum for the first 24 hours Rationale: Ice packs applied during the first 24 hours reduce edema, pain, and hematoma formation. After 24 hours, warm sitz baths can promote healing. Hard surfaces increase discomfort; cushioned rings or pillows are better. Perineal hygiene with warm water and gentle patting is essential to prevent infection. Question 37: A pregnant client at 38 weeks gestation reports decreased fetal movement. What is the priority nursing action? A. Reassure the client that this is normal near term B. Instruct the client to perform kick counts C. Schedule a routine prenatal visit next week D. Advise the client to drink caffeine to stimulate the fetus CORRECT ANSWER: B. Instruct the client to perform kick counts Rationale: Decreased fetal movement requires immediate assessment. Kick counts (counting 10 movements within 2 hours) help evaluate fetal well-being. If fewer than 10 movements are felt, the client should contact the provider immediately. Decreased movement is not normal and should never be dismissed. Caffeine is not recommended as a stimulus. Routine scheduling delays necessary evaluation. Question 38: A newborn is exhibiting jitteriness and irritability. The mother has a history of substance use. Which assessment is most important? A. Measure head circumference B. Assess for signs of withdrawal using a standardized scale C. Check blood glucose level D. Evaluate skin turgor CORRECT ANSWER: B. Assess for signs of withdrawal using a standardized scale Rationale: Given the maternal history, the newborn is at risk for Neonatal Abstinence Syndrome (NAS). Using a standardized assessment tool like the Finnegan Scale helps quantify withdrawal severity and guide treatment. While hypoglycemia can cause jitteriness, the maternal history makes withdrawal the primary concern. Head circumference and skin turgor are part of general assessment but not the priority here. Question 39: A nurse is teaching a pregnant client about danger signs in the third trimester. Which symptom requires immediate reporting? A. Braxton Hicks contractions B. Dependent edema C. Severe abdominal pain D. Backache
CORRECT ANSWER: C. Severe abdominal pain Rationale: Severe abdominal pain may indicate placental abruption, preterm labor, or other serious complications requiring immediate evaluation. Braxton Hicks contractions are normal practice contractions. Mild dependent edema is common. Backache is a typical discomfort of pregnancy. Severe or persistent pain is never normal. Question 40: A postpartum client is experiencing symptoms of postpartum blues. Which statement by the nurse is most appropriate? A. "This is abnormal and requires psychiatric hospitalization." B. "These feelings are common and usually resolve within two weeks." C. "You should stop breastfeeding immediately." D. "This indicates you are not bonding with your baby." CORRECT ANSWER: B. These feelings are common and usually resolve within two weeks. Rationale: Postpartum blues affect up to 80% of new mothers, typically beginning 2- 3 days postpartum and resolving within 2 weeks. Symptoms include mood swings, tearfulness, and anxiety. Reassurance and support are appropriate. Postpartum depression is more severe and persistent, requiring professional intervention. Blues do not require hospitalization, do not necessitate stopping breastfeeding, and do not indicate poor bonding. Question 41: A nurse is preparing to administer Rh immune globulin (RhoGAM). Which client is eligible? A. Rh-positive mother with Rh-positive infant B. Rh-negative mother with Rh-positive infant C. Rh-negative mother with Rh-negative infant D. Rh-positive mother with Rh-negative infant CORRECT ANSWER: B. Rh-negative mother with Rh-positive infant Rationale: RhoGAM is given to Rh-negative mothers who deliver Rh-positive infants to prevent isoimmunization. The mother's immune system may produce antibodies against Rh-positive blood, endangering future pregnancies. Rh-positive mothers do not need RhoGAM. Rh-negative mothers with Rh-negative infants do not need it because there is no antigen mismatch. Question 42: A client is experiencing precipitous labor. Which complication is the nurse monitoring for? A. Prolonged second stage B. Uterine rupture C. Postpartum hemorrhage D. Fetal macrosomia
Rationale: HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is a variant of preeclampsia characterized by right upper quadrant pain (from liver capsule distension), headache, visual disturbances, and hypertension. This is a medical emergency. Migraines do not cause RUQ pain. Gastroenteritis presents with GI symptoms. These are not normal postpartum findings. Question 46: A nurse is caring for a newborn with erythema toxicum. Which action is appropriate? A. Apply topical antibiotics B. Isolate the newborn from others C. Reassure parents that this is benign and self-limiting D. Obtain a culture of the lesions CORRECT ANSWER: C. Reassure parents that this is benign and self-limiting Rationale: Erythema toxicum is a common, benign newborn rash appearing as blotchy red spots with white or yellow centers. It requires no treatment and resolves spontaneously within days to weeks. Antibiotics, isolation, and cultures are unnecessary as it is not infectious. Question 47: A client in labor is receiving oxytocin augmentation. Which finding requires stopping the infusion? A. Contractions every 3 minutes lasting 60 seconds B. Fetal heart rate baseline of 140 bpm C. Contractions every 2 minutes lasting 90 seconds D. Urine output of 35 mL/hr CORRECT ANSWER: C. Contractions every 2 minutes lasting 90 seconds Rationale: Contractions more frequent than every 2 minutes or lasting longer than 90 seconds indicate tachysystole, which can compromise fetal oxygenation. The infusion should be stopped or reduced. Contractions every 3 minutes lasting 60 seconds are appropriate. A fetal heart rate of 140 is normal. Urine output of 35 mL/hr is acceptable (minimum 30 mL/hr). Question 48: A nurse is teaching a new mother about umbilical cord care. Which statement indicates understanding? A. "I should apply alcohol to the cord stump twice daily." B. "I should fold the diaper below the cord stump." C. "I should pull off the cord when it looks ready." D. "I should give tub baths before the cord falls off." CORRECT ANSWER: B. I should fold the diaper below the cord stump. Rationale: Folding the diaper below the cord keeps it dry and exposed to air, promoting healing and preventing contamination. Current guidelines recommend dry cord care (no alcohol) unless infection is present. The cord should fall off naturally, usually within 1- 2
weeks; pulling it can cause bleeding and infection. Sponge baths are recommended until the cord falls off. Question 49: A pregnant client at 34 weeks gestation reports painless, bright red vaginal bleeding. What condition does the nurse suspect? A. Placental abruption B. Placenta previa C. Cervical polyp D. Bloody show CORRECT ANSWER: B. Placenta previa Rationale: Painless, bright red vaginal bleeding in the third trimester is characteristic of placenta previa. Placental abruption typically presents with painful, dark red bleeding and uterine tenderness. Cervical polyps may cause spotting but not significant bleeding. Bloody show is mucus-tinged blood associated with cervical dilation near labor onset. Question 50: A newborn is noted to have milia on the face. What is the best nursing action? A. Squeeze the lesions to remove contents B. Apply antifungal cream C. Explain that these will resolve spontaneously D. Consult dermatology immediately CORRECT ANSWER: C. Explain that these will resolve spontaneously Rationale: Milia are tiny white cysts caused by blocked sebaceous glands, common in newborns. They resolve spontaneously within weeks without treatment. Squeezing can cause infection and scarring. Antifungal cream is unnecessary as milia are not fungal. Dermatology consultation is not needed for this benign condition. Question 51: A postpartum client is experiencing mastitis. Which intervention is appropriate? A. Stop breastfeeding on the affected side B. Apply cold compresses before feeding C. Continue breastfeeding or pumping frequently D. Administer antibiotics only if fever exceeds 102°F CORRECT ANSWER: C. Continue breastfeeding or pumping frequently Rationale: Frequent emptying of the breast through breastfeeding or pumping is essential to treat mastitis and prevent abscess formation. Breastfeeding should continue on the affected side; it is safe for the infant. Warm compresses before feeding promote milk flow; cold compresses after feeding reduce pain. Antibiotics are prescribed regardless of fever level once mastitis is diagnosed.
A. At the first prenatal visit B. At 24-28 weeks gestation C. At 35-37 weeks gestation D. Only if symptoms are present CORRECT ANSWER: C. At 35-37 weeks gestation Rationale: GBS screening is performed at 35-37 weeks gestation via rectovaginal culture. GBS colonization can be transient, so earlier testing may not reflect status at delivery. Positive results require intrapartum antibiotic prophylaxis to prevent neonatal GBS disease. It is not based on symptoms, as colonization is asymptomatic. Question 56: A postpartum client's fundus is displaced to the right. What is the most likely cause? A. Uterine atony B. Full bladder C. Retained placental fragments D. Broad ligament hematoma CORRECT ANSWER: B. Full bladder Rationale: A full bladder displaces the uterus upward and to the right (or left), preventing proper contraction and increasing hemorrhage risk. The nurse should assist the client to void or catheterize if necessary. Uterine atony causes a boggy fundus but not necessarily displacement. Retained fragments cause bleeding but not displacement. Hematoma may cause deviation but bladder distention is the most common cause. Question 57: A newborn has a positive Babinski reflex. How should the nurse interpret this finding? A. Neurological impairment B. Normal newborn reflex C. Sign of cerebral palsy D. Indicator of spinal cord injury CORRECT ANSWER: B. Normal newborn reflex Rationale: The Babinski reflex (toes fan outward when the sole is stroked) is normal in newborns and infants up to 12-24 months. Persistence beyond 2 years may indicate neurological problems. In adults, a positive Babinski is abnormal. In newborns, it reflects immature neurological development and is expected. Question 58: A pregnant client at 16 weeks gestation asks about amniocentesis. What is the primary indication for this test? A. Determining fetal sex for family planning B. Diagnosing chromosomal abnormalities
C. Assessing fetal lung maturity D. Evaluating amniotic fluid volume CORRECT ANSWER: B. Diagnosing chromosomal abnormalities Rationale: Amniocentesis at 15-20 weeks is primarily used to diagnose chromosomal abnormalities (e.g., Down syndrome) and genetic disorders. Fetal sex determination is possible but not the primary medical indication. Lung maturity assessment is done later in pregnancy (after 32 weeks) if early delivery is considered. Fluid volume is assessed via ultrasound, not amniocentesis. Question 59: A nurse is caring for a newborn with jaundice. Which type of jaundice appears within the first 24 hours? A. Physiologic jaundice B. Breastfeeding jaundice C. Pathologic jaundice D. Breast milk jaundice CORRECT ANSWER: C. Pathologic jaundice Rationale: Jaundice appearing within the first 24 hours is pathologic and requires investigation for causes such as hemolytic disease, infection, or metabolic disorders. Physiologic jaundice appears after 24 hours, peaks at days 3-5, and resolves by 1- 2 weeks. Breastfeeding jaundice occurs in the first week due to inadequate intake. Breast milk jaundice appears after day 5 and can persist for weeks. Question 60: A client in labor is experiencing back labor. Which intervention provides relief? A. Encourage supine positioning B. Apply counterpressure to the sacrum C. Administer general anesthesia D. Restrict movement CORRECT ANSWER: B. Apply counterpressure to the sacrum Rationale: Back labor, often associated with occiput posterior position, causes intense lower back pain. Counterpressure, sacral massage, and positional changes (hands- and-knees, side-lying) provide relief. Supine positioning worsens back pain and reduces placental perfusion. General anesthesia is not used for labor pain. Movement and position changes are encouraged. Question 61: A postpartum client is experiencing constipation. Which intervention is most appropriate? A. Administer a stimulant laxative immediately B. Encourage increased fluid and fiber intake C. Perform a digital stool removal D. Withhold pain medication
