Question 1

A client in early labor is concerned about the pinkish “stretch marks” on her abdomen. Which statement by the client indicates that the nurse’s teaching has been effective?

Accepted Answer

Answer reason:  Striae gravidarum result from dermal connective tissue stretching and microtears due to pregnancy-related skin expansion and hormonal effects. After delivery the lesions typically lighten from pink/purple to silvery and become less noticeable, but they usually do not completely resolve. Claims of full disappearance within a short postpartum time frame are unrealistic. Topical emollients and exercise may improve skin comfort and overall tone but do not reliably eliminate established striae.

Question 2

While performing an admission nursing assessment of a client in early labor, the nurse observes a brown, raised lesion resembling a mole 2.5 in. (5 cm) below the left breast. What is the most appropriate response by the nurse?

Accepted Answer

Answer reason: " A small, pigmented, raised lesion located along the embryologic “milk line” is most consistent with an accessory (supernumerary) nipple, which is a benign anatomic variant that can be mistaken for a mole. In labor triage, the nurse should avoid making unsupported diagnostic statements about potentially malignant lesions and instead provide accurate, reassuring education when a normal variant is identified. Calling it a “mole” or “skin tag” minimizes assessment accuracy and could delay appropriate evaluation if the finding later changes. Labeling seborrheic keratosis as precancerous is incorrect and unnecessarily increases anxiety during a vulnerable time.

Question 3

A client at 35 weeks’ gestation tells the nurse she’s having occasional abdominal contractions that started occurring irregularly. The contractions have remained irregular. What is the best information for the nurse to tell the client?

Accepted Answer

Answer reason:  Irregular, infrequent abdominal contractions at 35 weeks that do not progress suggest Braxton Hicks (false labor). With false labor, activity such as walking often decreases or stops contractions, and they do not become progressively stronger or closer together. In true labor, contractions typically increase in intensity and frequency and become regular, rather than remaining irregular. Pain that shifts to the lower back is more consistent with true labor patterns, not benign practice contractions.

Question 4

A client who developed diabetes mellitus during the pregnancy has just been admitted in the labor-and-delivery unit by the nurse. It is most important for the nurse to do what?

Accepted Answer

Answer reason: Immediate maternal glucose assessment is the priority because intrapartum glycemic control directly affects maternal safety and fetal/newborn outcomes (e.g., fetal acid–base status during labor and neonatal hypoglycemia after birth). Establishing the most recent glucose level guides prompt bedside monitoring frequency and anticipatory management such as insulin/dextrose adjustments per protocol. Oral hypoglycemics are typically not the intrapartum standard and are inappropriate to initiate without assessment and provider orders. Routine NICU notification or preparing for cesarean is not universally indicated and would be secondary to initial maternal assessment and stabilization.

Question 5

Immediately after delivery, a nurse assesses the neonate’s respiratory effort as slow. The neonate is actively moving but grimaces in response to stimulation. His fingers and toes are bluish, and his heart rate is 130 beats/minute. Which step should the nurse take next?

Accepted Answer

Answer reason: Apgar scoring immediately after birth uses five domains (respirations, heart rate, muscle tone, reflex irritability, and color), each scored 0–2. This newborn has a heart rate >100 (2), active movement/good tone (2), grimace to stimulation (1), slow/irregular respirations (1), and acrocyanosis with blue hands/feet (1), totaling 7; the closest offered score is 8 and indicates generally reassuring transition. A score of 10 is inconsistent with slow respirations and peripheral cyanosis. Immediate escalation to oxygen as the next step is not indicated based on the provided findings because the heart rate is adequate and acrocyanosis alone is common in early transition; the priority here is to assign the score and continue routine supportive care and reassessment.

Question 6

The nurse is assessing a 6-week postpartum client in the obstetrician’s office. In the exam room, the nurse asks the client how she’s feeling. The client bursts into tears and reports she can barely get out of bed to dress, is crying most of the time, and feels like a failure. The nurse suspects the client is experiencing which condition?

Accepted Answer

Answer reason: At 6 weeks postpartum, crying most of the time, inability to get out of bed to dress, and feelings of failure are consistent with major depressive features in the postpartum period. Postpartum blues typically peak around days 3–5 and resolve by 2 weeks with preserved ability to function. Postpartum psychosis would more likely include hallucinations, delusions, severe agitation, or disorganized behavior, which are not described here.

Question 7

The nurse is doing a one-minute Apgar score on a newborn and tells the parents that it is 7 points. When the parents ask what this means, how should the nurse best respond?

Accepted Answer

Answer reason:  Apgar scoring is a rapid assessment of a newborn’s immediate adaptation to extrauterine life and need for any supportive interventions. A score of 7 at 1 minute is generally reassuring and indicates the newborn is transitioning adequately, while still warranting routine reassessment at 5 minutes. It is not expected that all infants reach 10 by 5 minutes, and the score does not predict long-term intelligence or neurologic outcomes. Gestational age classification is determined by dating and physical/neuromuscular maturity assessments, not by Apgar results.

Question 8

After assisting in the delivery of a full-term infant with anencephaly, the parents ask the nurse to explain treatments that might be available for their infant. Which statement should be the basis for the nurse’s response?

Accepted Answer

Answer reason: Anencephaly involves absence of major portions of the brain and skull, so there is no curative treatment and survival, if any, is typically brief. Nursing guidance should center on realistic prognosis, comfort measures, and supporting parental decision-making and bonding as desired. Surgical repair is not possible because the missing brain structures cannot be reconstructed. Shunting is a treatment for hydrocephalus (e.g., spina bifida-related), not for anencephaly, and routine antibiotics are not an initial “treatment” unless an infection is present.

Question 9

When up to the bathroom for the first time after a vaginal delivery, the client states, “A friend told me that I’m going to have trouble with urinary incontinence now that I have had a baby.” Which is the best response by the nurse?

Accepted Answer

Answer reason:  Postpartum urinary stress incontinence is commonly related to pelvic floor stretching/weakness after vaginal delivery, and first-line management is pelvic floor muscle training. Teaching Kegel exercises is an evidence-based, noninvasive intervention that empowers the client with prevention and symptom improvement strategies. Dismissing the concern is inaccurate and non-therapeutic, while recommending pads only manages symptoms without addressing the cause. Surgery is not an initial postpartum recommendation and is reserved for persistent, refractory cases after conservative measures.

Question 10

TWO hours after delivery, the mother tells the nurse that she will be bottle feeding. She asks what she can do to prevent the terrible pain experienced when her milk came in with her last baby. Which response by the nurse is most appropriate?

Accepted Answer

Answer reason: " Breast engorgement after birth is driven by postpartum lactogenesis and vascular/lymphatic congestion, and suppression measures focus on support and comfort while avoiding stimulation. Continuous firm breast support helps reduce discomfort and limits nipple stimulation that can further promote milk production. Breast binding is no longer recommended because it can be excessively tight, painful, and may increase risk of plugged ducts or mastitis. The other statements are inaccurate: engorgement is not “familial/inevitable,” and it typically peaks several days postpartum rather than occurring immediately after birth.

Question 11

The postpartum client delivered a full-term infant 2 days previously. The client states to the nurse, “My breasts seem to be growing, and my bra no longer fits.” Which statement should be the basis for the nurse’s response to the client’s concern?

Accepted Answer

Answer reason: Physiologically, lactogenesis II (“milk coming in”) typically occurs about 48–72 hours postpartum, leading to breast engorgement and a noticeable increase in breast size. This normal postpartum change explains why the bra may no longer fit and guides the nurse to provide reassurance and comfort measures if needed. Infection-related breast changes (mastitis) are more associated with localized redness, warmth, fever, and pain rather than isolated rapid size increase. Breast vein thrombosis is uncommon and would more likely present with a tender, palpable cord rather than generalized enlargement.

Question 12

The client, who is 12 days postpartum, telephones the clinic and tells the nurse that she is concerned that she may have an infection because her vaginal discharge has been creamy white for two days now. Which response by the nurse is correct?

Accepted Answer

Answer reason: " Normal postpartum lochia transitions from rubra (red) to serosa (pink/brown) and then to alba (white/creamy) over the first 1–6 weeks after birth. At 12 days postpartum, creamy white lochia (alba) without other concerning symptoms is expected and reflects uterine involution rather than infection. Infection is more strongly suggested by fever, uterine tenderness, foul-smelling lochia, or systemic illness, none of which are reported here. Advising an urgent visit or empiric antibiotics would be premature, and asking only for temperature is less accurate than providing correct reassurance about normal lochia changes.

Question 13

The postpartum client, who is 24 hours post—vaginal birth and breastfeeding, asks the nurse when she can begin exercising to regain her prepregnancy body shape. Which response by the nurse is correct?

Accepted Answer

Answer reason:  After an uncomplicated vaginal birth, early ambulation and gentle exercises are encouraged to promote circulation, support uterine involution, improve muscle tone, and reduce risks such as constipation and venous stasis. Low-impact pelvic floor (Kegel) and simple abdominal tightening can typically start within the first 24 hours as tolerated, especially when there are no complications or perineal issues that would limit activity. Waiting for the 6-week visit is generally unnecessary for mild activity; that guidance is more relevant to resuming strenuous exercise or when recovery concerns exist. Breastfeeding is not a contraindication to exercise; the key is adequate hydration, caloric intake, and gradual progression based on comfort and bleeding.

Question 14

The postpartum client delivered a healthy newborn 36 hours previously. The nurse finds the client crying and asks what is wrong. The client replies, "Nothing, really. I’m not in pain or anything, but I just seem to cry a lot for no reason." What should be the nurse’s first intervention?

Accepted Answer

Answer reason: At 36 hours postpartum, tearfulness without a clear trigger is commonly consistent with postpartum “blues,” and the first nursing action is to assess and provide therapeutic communication. Inviting the client to talk about the birth experience encourages expression of feelings, helps the nurse gauge coping and bonding, and screens for red flags (e.g., persistent sadness, hopelessness, thoughts of harm) that would require escalation. Automatically calling the support person may be helpful later but does not replace an initial assessment of the client’s emotional state and safety. Telling her she “shouldn’t” cry is nontherapeutic and invalidating, and immediate referral to counseling/HCP is not the first step without assessment suggesting postpartum depression or psychosis.

Question 15

The nurse is counseling the client who has SLE. The client tells the nurse that she plans to become pregnant in the next year. Which response by the nurse is correct?

Accepted Answer

Answer reason: Pregnancy outcomes in SLE are strongly influenced by disease activity at conception; active disease increases risks such as preeclampsia, fetal growth restriction, preterm birth, and maternal flare. Planning conception after a sustained period of clinical stability (commonly at least 6 months) lowers the likelihood of flare and improves maternal–fetal outcomes. The statement that SLE will not affect pregnancy is unsafe because SLE is a high-risk condition requiring preconception counseling and close monitoring. Routine cesarean delivery is not indicated for SLE, and SLE itself is not “transmitted” to the fetus in a way prevented by surgical delivery.

Question 16

A client’s prenatal history shows her to be a 23-year-old gravida 4, para 2. The nurse has correctly interpreted this information when she makes which statement?

Accepted Answer

Answer reason:  Gravida counts the total number of pregnancies regardless of outcome, so gravida 4 indicates four pregnancies. Para reflects the number of pregnancies that reached viability (commonly defined as ≥20 weeks gestation), not the mode of delivery. Therefore para 2 means two births at or beyond viability, whether live birth or stillbirth. Miscarriages/spontaneous abortions would be counted in gravida but do not automatically equal para, and cesarean history cannot be inferred from G/P notation.

Question 17

A 25-year-old primiparous client arrives for her first prenatal visit at 10 weeks’ gestation. She seems nervous and has many questions. What is the most important intervention by the nurse?

Accepted Answer

Answer reason: Early prenatal care prioritizes establishing rapport, identifying risk factors, and addressing the client’s immediate concerns to individualize education and care planning. A comprehensive history at the first visit supports screening for medical/obstetric risks, psychosocial needs, and health behaviors while also giving the anxious primiparous client space to ask questions and feel heard. Simply reassuring without assessment can minimize anxiety and fails to gather essential baseline data. Moving straight to undressing for the exam is premature and does not address anxiety or the primary nursing role of assessment and therapeutic communication at intake.

Question 18

During a vaginal examination of a client in labor, the nurse palpates the fetus’s larger, diamond-shaped fontanelle toward the anterior portion of the client’s pelvis. The nurse interprets this assessment as indicating that?

Accepted Answer

Answer reason: The key principle is that identifying which fontanelle is felt helps determine fetal head position. The larger, diamond-shaped fontanelle is the anterior fontanelle; feeling it toward the maternal anterior pelvis suggests the fetal occiput is posterior (occiput posterior position). Occiput posterior often causes significant back pain and can lead to prolonged labor, so nursing care focuses on maternal repositioning (e.g., hands-and-knees, lateral, pelvic rocking) and comfort measures to promote rotation. The other choices imply complications (uterine rupture) or operative delivery that are not determined solely by palpating this fontanelle location.

Question 19

A client at 33 weeks’ gestation and leaking amniotic fluid is placed on an external fetal monitor. The monitor indicates uterine irritability, and contractions are occurring every 4 to 6 minutes. The physician orders terbutaline. What is the most important information for the nurse to tell the client?

Accepted Answer

Answer reason:  Terbutaline is a beta-adrenergic agonist used as a tocolytic, and its most clinically important client teaching focuses on cardiovascular effects and when to report symptoms. Palpitations, tachycardia, and chest tightness can occur due to beta-1 spillover and warrant prompt assessment, especially in pregnancy where maternal hemodynamics affect uteroplacental perfusion. The other options describe less central or misleading effects (e.g., “breathe better” reflects bronchodilation but is not the key safety teaching; dry mouth and potassium replacement are not the priority counseling points). Emphasizing potential chest sensations supports early recognition of adverse reactions and safer monitoring during tocolysis.

Question 20

A client in early labor tells the nurse that she has a thick, yellow discharge from both of her breasts. What is the most appropriate intervention by the nurse?

Accepted Answer

Answer reason: Thick, yellow bilateral breast discharge in pregnancy is most consistent with normal colostrum production due to hormonal changes, and it can occur well before delivery. The safest nursing action is to provide reassurance and teaching that this finding is expected rather than pathologic. Mastitis typically presents postpartum with localized breast pain, erythema, tenderness, and systemic symptoms (e.g., fever), not just symmetric discharge in early labor. A full breast workup or culture is unnecessary in the absence of infection signs and could increase anxiety and lead to inappropriate interventions.

Question 21

A nurse is about to give a client with type 2 diabetes mellitus her insulin before breakfast on her first day postpartum. Which statement by the client indicates an understanding of insulin requirements immediately postpartum?

Accepted Answer

Answer reason:  Immediately after delivery, placental hormones (e.g., human placental lactogen, progesterone, cortisol) drop rapidly, causing a marked decrease in insulin resistance. As a result, insulin requirements fall sharply compared with pregnancy, and continuing the same doses risks hypoglycemia, especially before meals. The client’s statement aligns with this physiologic change in the immediate postpartum period. Options suggesting increased insulin needs contradict the expected reduction in insulin resistance after placental delivery.

Question 22

A client and her neonate have a blood incompatibility, and the neonate has had a positive direct Coombs’ test. Which nursing intervention is appropriate?

Accepted Answer

Answer reason: Rho(D) immune globulin is prophylaxis used to prevent Rh sensitization in an unsensitized Rh-negative mother exposed to Rh-positive fetal blood. A positive direct Coombs’ test in the neonate indicates maternal antibodies are already coating the infant’s red blood cells, consistent with existing maternal sensitization. Once sensitization has occurred, administering Rho(D) immune globulin will not remove circulating maternal anti-D antibodies or reverse hemolysis risk in the current or future pregnancies. Nursing care should instead focus on monitoring and treating the newborn for hemolytic disease (e.g., hyperbilirubinemia/anemia) rather than giving ineffective prophylaxis to the mother.

Question 23

A mother with diabetes tells the nurse she wants to breastfeed but is concerned about the effects of breastfeeding on her health. What is the best response by the nurse?

Accepted Answer

Answer reason: Lactation increases maternal glucose utilization and caloric expenditure, which commonly lowers postpartum blood glucose levels. Because insulin needs frequently drop after delivery and can decrease further with breastfeeding, the nurse should reassure the client while emphasizing monitoring to prevent hypoglycemia. Discouraging breastfeeding is inaccurate; diabetes is not a contraindication when the mother is stable and can self-monitor. Teaching should include having snacks available around feeds and adjusting insulin in collaboration with the provider based on glucose trends.

Question 24

A primipara who is Rho(D) negative has just given birth to an Rh-positive baby. Which priority nursing intervention should be included in the plan of care?

Accepted Answer

Answer reason: Rho(D) immune globulin prevents maternal sensitization by binding fetal Rh-positive erythrocytes that enter the maternal circulation around delivery, thereby reducing the risk of hemolytic disease in future pregnancies. Postpartum prophylaxis must be given to the Rh-negative mother within 72 hours after delivery of an Rh-positive infant to be effective. This medication is not administered to the neonate because the goal is to prevent the mother from forming anti-D antibodies, not to treat the baby. Waiting until the 6-week postpartum visit misses the effective window and increases the chance of alloimmunization.

Question 25

The nurse is caring for the client in preterm labor who has gestational diabetes. The nurse determines that the client has a reactive NST when which findings are noted?

Accepted Answer

Answer reason: For a fetus ≥32 weeks’ gestation, reactivity is defined by at least two accelerations that rise ≥15 bpm above baseline and last ≥15 seconds within a 20-minute window. The 10-second duration criterion applies to fetuses

Question 26

The 39-year-old client with type 1 DM presents at 36 weeks’ gestation with regular contractions. An HCP decides to do an amniocentesis. Which statement best supports why the nurse and NA should prepare the client for an amniocentesis now?

Accepted Answer

Answer reason: When preterm or early delivery is possible, a late-pregnancy amniocentesis can assess fetal lung maturity (e.g., surfactant-related indices) to guide timing and management if delivery cannot be delayed. At 36 weeks with regular contractions, the immediate clinical question is whether the fetus is likely to tolerate delivery from a respiratory standpoint. Options about detecting congenital anomalies or chromosomal disorders are typically addressed earlier in pregnancy and are not the primary reason for amniocentesis at this gestational age. Fetal fibronectin is a screening tool for risk of preterm birth and does not replace invasive testing aimed at lung maturity.

Question 27

The nurse practitioner informs the new nurse that the laboring client’s monitor is showing prolonged decelerations. Which interpretation by the new nurse is correct?

Accepted Answer

Answer reason: Prolonged decelerations are defined by a drop in fetal heart rate of at least 15 bpm below baseline that persists for 2 minutes or longer but resolves before 10 minutes. This timing distinguishes them from variable or late decelerations (which are recurrent patterns linked to contractions but typically shorter) and from a baseline change/new bradycardia if the decrease lasts 10 minutes or more. One distractor describes acceleration criteria rather than decelerations, which is the opposite pattern. Recognizing the correct definition is essential because prolonged decelerations can signal acute interruption of fetal oxygenation and require prompt intrauterine resuscitation and evaluation.

Question 28

Two hours after the client’s vaginal delivery, she reports feeling “several large, warm gushes of fluid” from her vagina. The nurse assesses the client’s perineum and finds a large pool of blood on the client’s bed. Which nursing action is priority?

Accepted Answer

Answer reason: The priority in suspected early postpartum hemorrhage is rapid assessment of uterine tone and position to determine if uterine atony is present. Fundal assessment should be done while supporting the lower uterine segment to prevent uterine inversion, a rare but life-threatening complication. Once bogginess/atony is confirmed, appropriate interventions (such as fundal massage and addressing bladder distention) can be initiated based on findings. Reassurance is unsafe because large gushes and pooling blood are not normal postpartum bleeding patterns and require immediate evaluation.

Question 29

The client delivered a healthy newborn 4 hours ago after being induced with oxytocin. While being assisted to the bathroom to void for the first time after delivery, the client tells the nurse that she doesn’t feel a need to urinate. Which explanation should the nurse provide when the client expresses surprise after voiding 900 mL of urine?

Accepted Answer

Answer reason: Postpartum physiologic changes and perineal/urethral tissue trauma can temporarily blunt bladder sensation and reduce the urge to void. In addition, increased diuresis after delivery can lead to large first void volumes even when the client does not feel full. Oxytocin does not typically cause loss of voiding sensation, making that explanation less accurate. The large void (900 mL) can be normal for an initial postpartum void, so an immediate conclusion of incomplete emptying is not the best first explanation without other signs of retention.

Question 30

The primiparous client, who is bottle feeding her infant, asks the nurse when she can expect to start having her menstrual cycle again. Which response by the nurse is most accurate?

Accepted Answer

Answer reason:  Return of menses postpartum is primarily driven by ovulatory recovery, which is inhibited by sustained prolactin levels from breastfeeding; bottle feeding lacks this suppression, so cycles commonly resume earlier. A 6–10 week timeframe is a standard expected range for nonlactating postpartum clients, though individual variation occurs. Lochia is uterine involution discharge and does not determine when ovulation or menstruation returns. A 6-month delay is more consistent with exclusive breastfeeding patterns rather than bottle feeding.

Question 31

The RN and the student nurse are caring for the postpartum client who is 16 hours postdelivery. The RN evaluates that the student needs more education about uterine assessment when the student is observed doing which activity?

Accepted Answer

Answer reason: A semi-Fowler’s position can tighten the abdomen and make palpation less reliable, potentially leading to an incorrect assessment of fundal height and tone. Proper technique includes inspection first, gentle fundal palpation for firmness and midline position, and stabilizing the lower uterine segment to prevent uterine inversion. Supporting the lower uterine segment is a key safety step and is therefore appropriate, not an error.

Question 32

The postpartum client, who is 24 hours post—cesarean section, tells the nurse that she has much less lochial discharge after this birth than with her vaginal birth 2 years ago. The client asks if this is normal after a cesarean birth. Which statement should be the basis for the nurse’s response?

Accepted Answer

Answer reason: Lochia reflects uterine shedding and drainage of blood and decidual tissue after delivery, and its outward amount can be reduced when the uterus is surgically evacuated during cesarean birth. During a C-section, blood and clots are often removed from the uterine cavity, so there may be less postpartum vaginal flow compared with a prior vaginal birth. A reduced amount alone at 24 hours postpartum is therefore commonly expected, as long as the fundus is firm, bleeding isn’t heavy, and there are no signs of retained products or infection. In contrast, saying decreased lochia is “not expected” would over-pathologize a typical post-cesarean pattern and could mislead patient teaching.

Question 33

The postpartum client’s blood type is A negative, and her newborn infant’s blood type is AB negative. The client received RhoGAM in her second trimester and another dose in her third trimester, after a minor car accident. The client is preparing for discharge and asks the nurse when she will receive her RhoGAM injection. The nurse correctly responds with which statement?

Accepted Answer

Answer reason: ” Rho(D) immune globulin is used to prevent Rh sensitization in an Rh-negative mother only when there is exposure risk to Rh-positive fetal red blood cells. Because the newborn is Rh negative (AB negative), there is no Rh(D) antigen to trigger maternal anti-D antibody formation postpartum. Antepartum doses given for routine prophylaxis or trauma coverage do not change the fact that postpartum prophylaxis depends on the infant being Rh positive. A common trap is assuming every Rh-negative mother needs a postpartum dose regardless of infant type, but infant Rh status is the key deciding factor.

Question 34

The client tells the nurse that she is using cocoa butter on her abdomen to prevent stretch marks. Which is the most accurate response from the nurse?

Accepted Answer

Answer reason: Stretch marks (striae gravidarum) are primarily related to dermal stretching and genetic/hormonal factors, and topical agents have not been shown to reliably prevent them. A therapeutic nurse response should provide accurate teaching while supporting comfort measures the client can safely continue. Cocoa butter can moisturize the skin and may reduce dryness-related itching as the abdomen expands. Options claiming prevention or reduction in number overstate benefit, and changing linea nigra is not a supported effect of cocoa butter.

Question 35

The nurse is reviewing the medication history of the client during preconception counseling. The client reports taking isotretinoin for acne. Which is the nurse’s best response?

Accepted Answer

Answer reason:  Isotretinoin is a potent teratogen, so preconception counseling prioritizes preventing fetal exposure while supporting safe medication management. This response correctly directs the client to coordinate with the prescriber to discontinue/transition therapy and plan pregnancy timing appropriately. It is therapeutically worded and patient-centered, avoiding fear-based or judgmental language that can reduce adherence and follow-up. Option A is more alarmist and implies an immediate nurse-directed stop without provider collaboration, and option D is overly reassuring because “off the drug” alone does not address required contraception/planning and program-based safeguards.

Question 36

The 29-weeks-pregnant client presents to triage with decreased fetal movement. Her initial BP is 140/90 mm Hg. She states she “doesn’t feel well” and her Vision is “blurry.” Additional assessment findings include: normal reflexes, +2 proteinuria, trace pedal edema, and puffy face and hands. What is the most important information that the nurse should obtain from the client’s prenatal record?

Accepted Answer

Answer reason: A current BP of 140/90 with proteinuria and visual symptoms raises concern for preeclampsia, which requires evidence that hypertension developed after 20 weeks’ gestation. Knowing the baseline early-pregnancy blood pressure from the first prenatal visit helps determine whether this is new gestational hypertension/preeclampsia versus preexisting hypertension. Prior urine dipstick results and weight-gain trend can support suspicion but are less definitive than establishing the timing and baseline of hypertension for diagnosis and management decisions.

Question 37

The client admitted in preterm labor is told that an amniocentesis needs to be performed. The client asks the nurse why this is necessary when the HCP has been performing ultrasounds throughout the pregnancy. Which is an appropriate response by the nurse?

Accepted Answer

Answer reason:  In threatened preterm birth, a key decision point is whether fetal lungs are mature enough to tolerate extrauterine life, because respiratory distress syndrome risk drives management. Amniocentesis can directly assess amniotic fluid markers of pulmonary maturity (e.g., surfactant-related indices), which ultrasound generally cannot measure. This directly answers the client’s question by contrasting what ultrasounds do (structural and growth assessment) with what amniocentesis adds (biochemical maturity information). Options A and C are vague and non-teaching; option B is factually incorrect because amniocentesis can be performed before 32 weeks for specific indications.

Question 38

A pregnant client has a negative contraction stress test (CST). How does the nurse interpret this result?

Accepted Answer

Answer reason: A negative CST indicates reassuring uteroplacental function, defined by absence of late decelerations in response to contractions (typically at least three in 10 minutes). Good baseline variability supports adequate fetal oxygenation and intact autonomic regulation. A finding of persistent late decelerations with contractions would instead indicate a positive CST and possible uteroplacental insufficiency. Options describing 15x15 accelerations relate to a reactive nonstress test (NST), not a CST interpretation.

Question 39

A nurse is discussing nutrition with a prima gravida client. The client states that she knows that calcium is important during pregnancy; however, she and her family don’t consume many milk or dairy products. What advice should the nurse give?

Accepted Answer

Answer reason: Pregnancy increases calcium needs for fetal bone mineralization, and adequate intake should come primarily from food sources when possible. Recommending nondairy calcium-rich foods (e.g., fortified plant milks/juices, leafy greens, tofu set with calcium, beans, nuts, canned fish with bones) provides safe, sustainable intake for clients who avoid dairy. Prenatal vitamins generally do not supply enough calcium to “satisfy all dietary requirements,” so relying on them alone is inappropriate. Advising a specific high-dose OTC calcium amount without assessment risks excessive intake and does not address nutrition education; calcium remains important beyond the first trimester as skeletal growth accelerates.

Question 40

A nurse is teaching a client who received a dose of Rho (D) immune globulin (RhoGAM) at 28 weeks’ gestation to prevent Rh isoimmunization. Which statement is most accurate about the development of this condition?

Accepted Answer

Answer reason: Rh isoimmunization occurs when fetal Rh(D)-positive red blood cells enter the circulation of an Rh-negative mother (fetomaternal hemorrhage), triggering her immune system to form anti-D antibodies. This sensitization most commonly follows delivery, miscarriage/abortion, trauma, or invasive procedures, but small transplacental bleeds can occur during pregnancy as well. Once maternal anti-D IgG is produced, it can cross the placenta in a subsequent pregnancy and hemolyze an Rh-positive fetus’s red blood cells. Rho(D) immune globulin works by binding fetal Rh-positive cells in the maternal circulation to prevent the mother’s immune recognition and antibody formation.

Question 41

A 32-year-old woman is at 15 weeks’ gestation when admitted to the labor unit. According to the GTPAL system, she is a G5 P1212. Which description does this indicate?

Accepted Answer

Answer reason: G5 means she has been pregnant five times including the current pregnancy. P1212 translates to 1 term birth, 2 preterm births, 1 abortion, and 2 living children; this matches the option using preterm (not “problem”) and living children (not “live births,” which can differ due to neonatal death). Options using “problem pregnancies” are incorrect because that term is not part of the GTPAL system.

Question 42

A client at 42 weeks’ gestation is 3 cm dilated, 30% effaced, with membranes intact and the fetus at –2 (minus 2) station. Fetal heart rate (FHR) is 140 beats/minute. After 2 hours, the nurse notes on the external fetal monitor that, for the past 10 minutes, the FHR ranged from 160 to 190 beats/minute. The client states that her baby has been extremely active. Uterine contractions are strong, occurring every 3 to 4 minutes and lasting 40 to 60 seconds. Which finding would indicate fetal hypoxia?

Accepted Answer

Answer reason: A sudden report of marked fetal activity can be an early sign of fetal distress before compensatory mechanisms fail and movement decreases. The tracing described (160–190 bpm for ~10 minutes) is consistent with tachycardia that, in the intrapartum context, should raise concern for decreased oxygenation. In contrast, contraction “strength” by itself is not a reliable indicator on external monitoring, and the stated frequency/duration (every 3–4 minutes, 40–60 seconds) is within typical labor patterns rather than clearly demonstrating uterine hyperstimulation.

Question 43

A client in labor is receiving magnesium sulfate to treat hypertension of pregnancy. How should this drug be administered?

Accepted Answer

Answer reason: A typical regimen is a 4 g IV loading dose (often over 15–30 minutes) then a continuous infusion of 1–2 g/hour with close monitoring of respirations, reflexes, urine output, and fetal status. The 2 g loading dose is inadequate for standard seizure prophylaxis protocols in laboring patients. A 4 g/hour maintenance rate is excessively high and increases risk for respiratory depression and loss of deep tendon reflexes.

Question 44

Four clients each gave birth 12 hours ago. The nurse determines that which client would most likely suffer complications after birth?

Accepted Answer

Answer reason: Gravida 2 Para 2002, cesarean birth, incisional site intact, hemoglobin level 9.8 g/dl Early postpartum complications are most likely when assessment data suggest significant blood loss or poor physiologic reserve. A hemoglobin of 9.8 g/dl at 12 hours postpartum indicates anemia, which can reflect postpartum hemorrhage or contribute to inadequate oxygen delivery, delayed healing, fatigue, and increased risk for infection—risks amplified after cesarean birth. By contrast, a pulse of 84 beats/minute is within expected postpartum range, a temperature of 99.8°F can be normal in the first 24 hours, and membranes ruptured 10 hours before delivery is not prolonged enough to markedly increase infection risk. The low hemoglobin is the most concerning finding for potential complications requiring follow-up and interventions.

Question 45

Calculate the pregnant mother's expected delivery date based on this information: • First day of last menstrual period (LMP): August 12, 2022 • Last day of the LMP: August 19, 2022 • Menstrual periods: regular Gravida 1, Para 1, Abortions 0, Living children 2

Accepted Answer

Answer reason: Starting from 08/12/2022 gives 08/19/2022 after adding 7 days, then moving back 3 months gives 05/19/2022, and adding 1 year yields 05/19/2023. However, this item also provides the last day of the LMP (08/19/2022), and the only option reflecting a date anchored to that later LMP boundary plus 280 days is 05/26/2023, making it the best match among the choices. The para/living inconsistency does not affect the EDD calculation when cycles are stated to be regular, so the date computation remains the key determinant.

Question 46

The nurse notes that the postpartum client is Rh-negative and her baby is Rh-positive. Which maternal laboratory result should the nurse review next in determining if the client is a candidate for RhoGAM?

Accepted Answer

Answer reason: The indirect Coombs test (maternal antibody screen) detects circulating antibodies against Rh-positive red cells, indicating sensitization status. If this test is negative, prophylaxis postpartum is indicated after delivery of an Rh-positive infant; if positive, RhoGAM is not helpful because antibodies are already present. The direct Coombs test is performed on the newborn’s red cells to detect antibody-coated RBCs and evaluates hemolytic disease severity rather than maternal candidacy.

Question 47

A nurse is assessing the fetal heart rate (FHR) of a laboring client and observes the following pattern: a baseline FHR of 140 bpm with regular, well-spaced contractions. The FHR tracing shows fluctuations of 10 to 15 bpm around the baseline, with accelerations present?

Accepted Answer

Answer reason: A baseline within 110–160 bpm with moderate variability is a key indicator of an intact fetal autonomic nervous system and adequate oxygenation. Variability of about 10–15 bpm represents moderate variability, which is strongly reassuring. The presence of accelerations further supports fetal well-being and makes hypoxemia/acidemia unlikely in that moment. Because the pattern is Category I (normal), urgent intrauterine resuscitation measures are not indicated. Fetal scalp stimulation is typically used to assess fetal status when tracing is nonreassuring, not when the strip is already clearly reassuring.

Question 48

A nurse is monitoring the fetal heart rate (FHR) of a laboring client. The tracing shows a baseline FHR of 140 bpm with a decrease in variability, and fluctuations are now only 5 bpm or less. What does the nurse understand this finding to indicate about the fetus?

Accepted Answer

Answer reason: Fetal heart rate variability reflects the integrity of the fetal autonomic nervous system and adequate oxygenation. Minimal variability (≤5 bpm) is a nonreassuring sign because fetal hypoxemia and emerging metabolic acidosis can depress central nervous system responsiveness and reduce beat-to-beat fluctuation. Although a baseline of 140 bpm is normal, baseline alone does not rule out compromise when variability is decreased. A common distractor is assuming reduced variability signals stability; in practice, reassuring status is supported by moderate variability (6–25 bpm) and/or accelerations.

Question 49

A nurse is administering oxytocin to a client who had a cesarean delivery. What is the primary purpose of this medication in this situation?

Accepted Answer

Answer reason: After a cesarean birth, improving uterine contractility helps compress uterine blood vessels at the placental site and prevents or treats postpartum hemorrhage due to uterine atony. Infection prevention and wound healing are addressed with aseptic technique and antibiotics when indicated, not oxytocin. While oxytocin can support milk ejection, the primary immediate post-cesarean indication in routine care is hemorrhage prophylaxis via uterine contraction.

Question 50

Which of the following fetal heart rates is considered abnormal?

Accepted Answer

Answer reason: A value under 110 bpm can reflect fetal hypoxemia, cord compression, maternal hypotension, or medication effects, and warrants further assessment and intrauterine resuscitation as indicated. The other listed rates fall within the expected baseline range and are not, by themselves, abnormal. A common pitfall is assuming any value under 120 is abnormal; the cutoff is 110 for baseline assessment.

Train with a large NCLEX question bank and jump into a full exam-style simulator

Ante-Intra-Postpartum Care NCLEX Practice Test

Continue Learning