Question 1

The safest method of tetanus prevention in newborn is?

Accepted Answer

Answer reason: Maternal tetanus toxoid (TT) immunization during pregnancy leads to transplacental transfer of protective IgG antibodies to the fetus, providing passive immunity in the early neonatal period when neonatal tetanus risk is highest. Vaccinating the father does not confer passive protection to the newborn. Antibiotics at birth are not a reliable or appropriate preventive strategy for tetanus, and OPV (oral polio vaccine) is unrelated to tetanus prevention.

Question 2

Preterm labour is defined as labour occurring before how many completed weeks of gestation?

Accepted Answer

Answer reason: Preterm labor is classically defined as the onset of regular uterine contractions with cervical change before 37 completed weeks of gestation. Delivery at or after 37 weeks is considered term, so labor before this threshold is categorized as preterm. Options such as 28 or 34 weeks refer to earlier gestational subcategories but do not define preterm labor as a whole. Therefore, 37 weeks is the correct cutoff.

Question 3

Which of the following is a routine supplement given during pregnancy?

Accepted Answer

Answer reason: Routine prenatal supplementation commonly includes folic acid to reduce the risk of neural tube defects and iron to prevent/treat iron-deficiency anemia due to increased maternal blood volume and fetal needs. Vitamin C is not routinely prescribed as a standard prenatal supplement, and vitamin K prophylaxis is classically for the newborn rather than the pregnant client. Calcium may be recommended based on diet/risk, but “calcium carbonate only” omits essential routine prenatal needs like folic acid and iron.

Question 4

In twin pregnancy, the most dangerous complication is?

Accepted Answer

Answer reason: Twin-to-twin transfusion syndrome (TTTS) is a severe complication unique to monochorionic twin pregnancies due to placental vascular anastomoses, causing hemodynamic imbalance between donor and recipient twins. It can rapidly lead to fetal heart failure, severe anemia/polycythemia, hydrops, and high perinatal morbidity and mortality if untreated. While preterm labor, malpresentation, and postpartum hemorrhage are common in twin gestations, they are generally more manageable and less uniquely catastrophic than TTTS when it occurs. Therefore, TTTS is considered the most dangerous complication among the choices.

Question 5

Which of the following is considered a high risk factor in pregnancy?

Accepted Answer

Answer reason: Extremes of maternal age (35) are associated with increased obstetric and neonatal complications, including preterm birth, growth restriction, and hypertensive disorders. A history of previous stillbirth is a significant risk factor for adverse outcomes in subsequent pregnancies and warrants higher-risk surveillance. Since each listed condition independently increases pregnancy risk, the best answer is that all are high-risk factors.

Question 6

How often should antenatal visits occur in the third trimester?

Accepted Answer

Answer reason: In routine, low-risk prenatal care, visit frequency typically increases as pregnancy advances to allow closer monitoring for complications such as hypertension/preeclampsia, fetal growth issues, and preterm labor. Common schedules are every 4 weeks until about 28 weeks, every 2 weeks from about 28 to 36 weeks, then weekly from 36 weeks to delivery. Therefore, a standard third-trimester interval is every 2 weeks. Weekly visits are usually reserved for the late third trimester (around 36 weeks onward).

Question 7

The first stage of labour begins with?

Accepted Answer

Answer reason: The first stage of labor starts with the onset of true (regular) uterine contractions that produce progressive cervical effacement and dilation. It ends at full cervical dilatation (10 cm), which is the transition to the second stage. Delivery of the baby occurs in the second stage, and expulsion of the placenta defines the third stage. Therefore, the onset of regular uterine contractions is the best answer.

Question 8

The nurse is assessing fetal heart rate in a pregnant patient. The nurse records a pulse of 82 beats per minute. The nurse should ________?

Accepted Answer

Answer reason: A fetal heart rate is typically about 110–160 bpm; a reading of 82 bpm is more consistent with the maternal pulse being picked up by the Doppler. The first, safest troubleshooting step is to reposition/move the Doppler to locate the fetal heart tones, often by adjusting placement based on gestational age and fetal position. Calling the physician immediately is premature before confirming whether the reading is truly fetal. Using gel/lubricant or switching devices can help signal quality, but correct transducer placement is the most direct correction.

Question 9

What is the priority right after delivery?

Accepted Answer

Answer reason: Immediately after delivery, the most urgent maternal priority is preventing postpartum hemorrhage by ensuring the uterus is firm and well contracted. Fundal assessment and massage (when boggy) promotes uterine tone and reduces bleeding, addressing a life-threatening complication promptly. Starting IV fluids may support volume status but does not directly correct uterine atony. Antibiotics are not routine immediately post-delivery, and placing the baby on a warmer is less urgent than stabilizing maternal hemodynamics if hemorrhage risk is present.

Question 10

A pregnant woman's blood pressure is 150/100 mmHg. This suggests?

Accepted Answer

Answer reason: A blood pressure of 150/100 mmHg in pregnancy is hypertensive (≥140/90) and is concerning for a hypertensive disorder of pregnancy. In many nursing exam contexts, this is labeled pregnancy-induced hypertension (gestational hypertension), especially when new-onset after 20 weeks without other preeclampsia features provided. It is not normal and not hypotension. Gestational diabetes is not diagnosed by blood pressure readings.

Question 11

A nurse is assigned to a patient who is receiving oxytocin (Pitocin) to induce labor. The nurse terminates the oxytocin infusion if which of the following is noted on the assessment of the client?

Accepted Answer

Answer reason: Oxytocin can cause uterine tachysystole/hyperstimulation, leading to decreased uteroplacental perfusion and fetal hypoxia; this is an indication to stop the infusion immediately. The priority is preventing fetal compromise and maternal complications (e.g., uterine rupture). Early decelerations are typically benign and related to head compression, not an indication to stop oxytocin. Nausea and fatigue can occur in labor but are not criteria for terminating the infusion.

Question 12

A 30-year-old pregnant woman presents with mild fever, fatigue, and swollen glands. She is concerned about the possibility of Cytomegalovirus (CMV) infection. What is the nurse’s priority in assessing this patient?

Accepted Answer

Answer reason: For a pregnant client with nonspecific viral symptoms and concern for CMV, the nurse’s first priority is a focused assessment, including exposure history, to determine risk and guide appropriate provider notification and testing. CMV commonly spreads through close contact with body fluids (e.g., saliva/urine from young children), so identifying recent exposures is clinically actionable. A CBC is nonspecific and does not confirm CMV, and fetal ultrasound assessment is not the first nursing assessment step in a mildly symptomatic, stable client. A sexual history may be relevant but is less central than broader exposure history for CMV risk assessment in pregnancy.

Question 13

Fetal tachycardia is most common during?

Accepted Answer

Answer reason: Maternal fever commonly causes fetal tachycardia because an increase in maternal temperature increases fetal metabolic rate and oxygen demand, leading to a higher baseline fetal heart rate. By contrast, umbilical cord prolapse more typically produces fetal bradycardia and variable decelerations due to acute cord compression. Regional anesthesia is more associated with maternal hypotension and resultant fetal heart rate decelerations. Magnesium sulfate tends to decrease fetal heart rate variability and can cause neonatal depression rather than tachycardia.

Question 14

Isoimmunization can be prevented by giving Anti-D immunoglobulin within?

Accepted Answer

Answer reason: Anti-D immunoglobulin (RhIG) is given to an Rh-negative mother after delivery of an Rh-positive infant to prevent maternal sensitization from fetal Rh-positive red cells entering maternal circulation. The recommended time window for maximum effectiveness is within 72 hours postpartum (though some benefit may remain if given later). Giving it within this period helps prevent formation of maternal anti-D antibodies that could cause hemolytic disease of the fetus/newborn in future pregnancies. Therefore, 72 hours of delivery is the best answer.

Question 15

Breastfeeding should be initiated within how much time after birth?

Accepted Answer

Answer reason: Breastfeeding is recommended to begin as soon as possible after birth, ideally within the first hour, when the newborn is typically alert and demonstrates strong suckling reflexes. Early initiation supports intake of colostrum, helps prevent neonatal hypoglycemia, and promotes bonding. It also stimulates maternal oxytocin release, enhancing uterine involution and reducing postpartum bleeding. Delays of several hours to days are associated with lower breastfeeding success and missed early physiologic benefits.

Question 16

Folic acid helps prevent neural tube defects in pregnancy. A patient asks "What is the recommended dose and when should I start taking it?"?

Accepted Answer

Answer reason: For individuals who could become pregnant, the standard recommendation is folic acid 0.4 mg (400 mcg) daily starting at least 1 month before conception and continuing through early pregnancy to reduce neural tube defects, which occur very early in gestation. Starting before pregnancy is emphasized because neural tube closure happens by about 4 weeks gestation, often before pregnancy is recognized. The 4.4 mg dose is not the routine recommendation; higher-dose folate (typically 4 mg) is reserved for high-risk situations such as a prior neural tube defect-affected pregnancy.

Question 17

With a fetus in the left-anterior breech presentation, the nurse would expect the fetal heart rate would be most audible in which of the following areas?

Accepted Answer

Answer reason: In a breech presentation, the fetal head is up in the uterine fundus, so the fetal heart tones are typically best heard above the maternal umbilicus. The “left-anterior” position indicates the fetal back is on the maternal left side and oriented anteriorly, which is where heart tones are most easily transmitted. Therefore, the most audible location is above the umbilicus and to the left of the midline. Locations below the umbilicus are more typical of cephalic (vertex) presentations.

Question 18

Fundal height at 20 weeks of gestation is approximately at the level of?

Accepted Answer

Answer reason: By approximately 20 weeks’ gestation, the uterine fundus is expected to be at about the level of the umbilicus. Earlier, at around 16 weeks, the fundus is typically midway between the symphysis pubis and the umbilicus, and by term it rises toward the xiphoid. Therefore, the umbilicus is the best landmark for 20 weeks.

Question 19

The gestational age for extreme preterm birth is?

Accepted Answer

Answer reason: Extreme preterm birth is commonly defined as delivery before 28 weeks’ gestation. This category reflects the highest neonatal morbidity and mortality due to marked immaturity of the lungs, brain, and gastrointestinal system. The other ranges correspond to later preterm categories (very/moderate/late preterm) rather than extreme preterm.

Question 20

Cord clamping in normal delivery should be done ...?

Accepted Answer

Answer reason: In normal (vigorous) term newborns, delayed cord clamping is recommended, typically around 1–3 minutes after birth. This timing allows placental transfusion, which increases neonatal blood volume and iron stores and reduces risk of iron-deficiency anemia. Immediate clamping is generally reserved for situations requiring urgent neonatal resuscitation or maternal instability, not routine uncomplicated delivery.

Question 21

At what gestational age do fetal movements usually become visible externally to the mother?

Accepted Answer

Answer reason: Maternal perception of fetal movement (quickening) is typically around 16–20 weeks, and by about 20–22 weeks fetal movements are commonly strong enough to be visible externally on the maternal abdomen. Earlier gestational ages (8–14 weeks) can have fetal movement on ultrasound but are not usually felt or seen by the mother. Much later ages (28–30 weeks) would be beyond the usual time when movements first become externally visible.

Question 22

Gravida refers to which of the following descriptions?

Accepted Answer

Answer reason: Gravida (G) is an obstetric history term that counts the total number of times a person has been pregnant, regardless of pregnancy outcome (including current pregnancy, miscarriages, and abortions). In contrast, para (P) refers to the number of pregnancies that reached viability, and it can be further broken down into term, preterm, abortions, and living children (TPAL). Therefore, the best definition among the options is the number of times a female has been pregnant. Options referring to delivered children or term pregnancies describe parity components, not gravida.

Question 23

A nurse in a PP unit is instructing a mother regarding lochia and the amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed the need for?

Accepted Answer

Answer reason: Normal postpartum lochia should gradually decrease in amount and change in color over time; it should not be heavy like a menstrual hemorrhage. Needing to change more than about 1 pad every few hours, passing large clots, or saturating a pad in an hour suggests abnormal bleeding and requires evaluation for postpartum hemorrhage. Among the options, “three peripads per day” best reflects a normal upper limit for expected lochia, whereas 8 pads/day implies excessive bleeding. One or two pads/day may occur but are not appropriate as the maximum threshold.

Question 24

What do you call the lochia during the first 3 days post-partum?

Accepted Answer

Answer reason: Lochia rubra is the normal postpartum uterine discharge seen in approximately the first 3 days after delivery and is characterized by a bloody, red appearance due to blood and decidual tissue. Lochia serosa typically follows (about days 4–10) and becomes pinkish-brown as bleeding decreases. Lochia alba occurs later (after about day 10) and is whitish/yellow as leukocytes and mucus predominate. Therefore, the first 3 days postpartum is lochia rubra.

Question 25

Normal weight gain in pregnancy ...?

Accepted Answer

Answer reason: For a singleton pregnancy in a person with a normal pre-pregnancy BMI, recommended total gestational weight gain is approximately 11.5–16 kg (about 25–35 lb). Among the options provided, 10–12.5 kg is the closest to the lower end of the recommended range and best represents “normal” weight gain. The other ranges listed are either too low (risking fetal growth restriction) or too broad/nonspecific to be considered the standard recommendation.

Question 26

When the deceleration pattern of the fetal heart rate mirrors the uterine contraction, which nursing action is indicated?

Accepted Answer

Answer reason: A deceleration pattern that mirrors the uterine contraction describes early decelerations, which are typically caused by fetal head compression during labor. Early decelerations are generally benign and expected when cervical dilation and fetal descent occur. Therefore, the appropriate nursing action is to continue monitoring and document the finding rather than initiating intrauterine resuscitation measures. Interventions like repositioning or fluid bolus are more appropriate for patterns suggesting uteroplacental insufficiency (e.g., late decelerations) or cord compression (variable decelerations).

Question 27

Which is the optimal fetal position for delivery?

Accepted Answer

Answer reason: The optimal fetal position for vaginal delivery is an occiput anterior (OA) position, most commonly left occiput anterior (LOA). In LOA, the fetal occiput is directed toward the maternal anterior pelvis, promoting flexion of the head and presenting the smallest diameter for passage through the pelvis. This alignment typically facilitates more efficient labor progress and reduces the likelihood of persistent occiput posterior or malposition-related complications. Sacral positions (LSA/RSA) do not describe the typical optimal cephalic vertex relationship for delivery compared with OA.

Question 28

Which fetal condition can result from APH?

Accepted Answer

Answer reason: Antepartum hemorrhage (APH), commonly due to placenta previa or placental abruption, can reduce effective uteroplacental perfusion and oxygen/nutrient delivery to the fetus. Chronic or recurrent placental bleeding and placental dysfunction can therefore lead to uteroplacental insufficiency and fetal growth restriction. The other options are not typical downstream fetal consequences of APH: polyhydramnios is more associated with diabetes or fetal anomalies, neonatal jaundice relates to bilirubin metabolism/hemolysis, and neural tube defects are early embryologic folate-related defects.

Question 29

Which is a sign of true labor?

Accepted Answer

Answer reason: True labor is characterized by regular, progressively stronger contractions that lead to cervical change, specifically progressive effacement and dilation. In contrast, false labor (Braxton Hicks) often presents with irregular contractions, minimal or no cervical change, and discomfort that may lessen with rest or sedation. Therefore, progressive cervical effacement is the key sign indicating true labor.

Question 30

Which condition is a contraindication for breastfeeding?

Accepted Answer

Answer reason: Maternal HIV infection is a classic contraindication to breastfeeding in settings where safe alternatives (formula feeding with clean water) are available, because HIV can be transmitted to the infant through breast milk. Mastitis is generally not a contraindication; continued breastfeeding or milk expression is usually recommended to maintain drainage. A common cold is not a contraindication; hand hygiene and masking reduce respiratory transmission. Tuberculosis that is on appropriate treatment is typically compatible with breastfeeding (with precautions early in treatment as indicated).

Question 31

A woman is in active labor and receives Stadol (butorphanol) 2mg for pain. Which of the following fetal heart responses would the nurse expect to see on the fetal heart monitor?

Accepted Answer

Answer reason: Butorphanol (Stadol) is an opioid agonist-antagonist analgesic that can cross the placenta and cause fetal central nervous system depression. This commonly manifests on the fetal heart rate tracing as decreased/"minimal" variability due to reduced autonomic responsiveness. Variable decelerations are more consistent with cord compression, and late decelerations suggest uteroplacental insufficiency; neither is the expected direct medication effect. Transient accelerations are generally reassuring and not the typical opioid-related finding.

Question 32

Which vaccine is SAFE for a client who is pregnant to receive?

Accepted Answer

Answer reason: Tdap is an inactivated (non-live) vaccine and is recommended during each pregnancy, typically between 27–36 weeks, to maximize maternal antibody transfer and protect the newborn from pertussis. Live attenuated vaccines are generally contraindicated in pregnancy due to theoretical risk to the fetus. Herpes zoster, varicella, and MMR are live vaccines and are avoided during pregnancy, instead given postpartum if indicated.

Question 33

Morning sickness usually occurs during?

Accepted Answer

Answer reason: Morning sickness (nausea and vomiting of pregnancy) most commonly occurs in the first trimester, peaking around 9–12 weeks. It is strongly associated with rising hCG and estrogen levels early in pregnancy. Symptoms typically improve as hormone levels stabilize in the second trimester, making the other options less accurate.

Question 34

A 23-year-old woman at 32-week gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication?

Accepted Answer

Answer reason: Glycosuria with ketonuria during pregnancy can indicate a metabolic complication such as gestational diabetes with inadequate caloric/carbohydrate intake or poor glucose control leading to ketosis. Ketones suggest fat breakdown and possible starvation ketosis or diabetic ketoacidosis risk, which warrants prompt evaluation. By contrast, mild dependent pedal edema at day’s end, increased vaginal discharge, and feeling diaphragmatic pressure with fetal movement are commonly reported physiologic changes in the third trimester when not accompanied by other concerning signs.

Question 35

A client at full dilation is pushing; the nurse notes shoulder dystocia after the head delivers and retracts ("turtle sign"). What is the priority maneuver?

Accepted Answer

Answer reason: Shoulder dystocia with the “turtle sign” is an obstetric emergency where first-line management is McRoberts maneuver (maternal hip hyperflexion) combined with suprapubic pressure to dislodge the impacted anterior shoulder from behind the pubic symphysis. Fundal pressure is contraindicated because it can worsen impaction and increase risk of uterine rupture or fetal injury. Encouraging breathing does not resolve the mechanical obstruction, and applying forceps is not a first-line intervention for true shoulder dystocia and can increase fetal trauma.

Question 36

Continuous fetal monitoring shows baseline 150, moderate variability, and early decelerations mirroring contractions in active labor at 7 cm. What should the nurse do?

Accepted Answer

Answer reason: Early decelerations that mirror uterine contractions with a normal baseline (150) and moderate variability are most consistent with fetal head compression during labor, which is a benign, expected finding. Moderate variability indicates adequate fetal oxygenation and neurologic function, making urgent interventions unnecessary. Therefore, appropriate nursing action is to continue monitoring and document the pattern as expected rather than initiating oxygen, stopping oxytocin, or calling the provider stat.

Question 37

A postpartum woman with Rh-negative blood gave birth to an Rh-positive baby. Her indirect Coombs test is negative. What is the nurse's priority?

Accepted Answer

Answer reason: An Rh-negative mother who delivers an Rh-positive infant is at risk for Rh sensitization when fetal blood enters maternal circulation. A negative indirect Coombs test indicates the mother is not yet sensitized, so prophylaxis is indicated. Rho(D) immune globulin should be administered within 72 hours postpartum to prevent maternal anti-D antibody formation and protect future pregnancies. The other options do not prevent alloimmunization and are not the immediate priority.

Question 38

A postpartum woman who had gestational diabetes is preparing for discharge. What should the nurse include in education?

Accepted Answer

Answer reason: A history of gestational diabetes significantly increases the mother’s lifetime risk of developing type 2 diabetes, so discharge teaching should emphasize this risk and the need for ongoing screening and lifestyle prevention. Option A is incorrect because postpartum follow-up glucose testing (e.g., 4–12 weeks postpartum and periodic screening thereafter) is recommended. Option C is incorrect because counseling should support healthy nutrition and weight management rather than endorsing a high-carbohydrate diet. Option D is not the best general teaching point because medication safety during breastfeeding depends on the specific agent and clinical context, and postpartum insulin resistance usually improves, so routine oral therapy is not universally indicated.

Question 39

Which discharge instruction is most important for a breastfeeding mother with cracked nipples?

Accepted Answer

Answer reason: For cracked nipples, applying lanolin is a standard first-line measure to promote moist wound healing and reduce pain while allowing continued breastfeeding. Using soap daily can dry and further irritate nipples, worsening cracking. Stopping breastfeeding is usually unnecessary and can lead to engorgement and decreased milk supply. Cold compresses may reduce discomfort but do not address the primary skin breakdown as effectively as lanolin.

Question 40

Which action promotes bonding and maternal role transition in the postpartum unit?

Accepted Answer

Answer reason: Rooming-in keeps the mother and newborn together, increasing opportunities for maternal–infant interaction, responsive feeding, and learning infant cues, all of which strengthen bonding and maternal role attainment. Separation (e.g., delaying contact until after cleaning) can reduce early attachment behaviors and interfere with breastfeeding initiation. Restricting visitors may reduce interruptions but is not the primary evidence-based intervention to promote bonding and role transition. Discharge forms support education but do not directly enhance early attachment like continuous mother–baby contact does.

Question 41

A postpartum mother with rubella non-immune status is being discharged. Which statement shows correct understanding?

Accepted Answer

Answer reason: A rubella non-immune postpartum client should receive the live-attenuated MMR vaccine prior to discharge to protect future pregnancies. Because it is a live vaccine, pregnancy should be avoided for at least 4 weeks after vaccination to reduce theoretical risk to a fetus. Rubella can cause serious congenital infection (congenital rubella syndrome), so it does affect newborns when infection occurs in pregnancy. Breastfeeding is not a contraindication to receiving MMR.

Question 42

On postpartum day 2, a mother is reluctant to care for her baby, saying "I'm too tired." What should the nurse do?

Accepted Answer

Answer reason: On postpartum day 2, fatigue, tearfulness, and feeling overwhelmed can be consistent with postpartum blues, which is common and usually self-limited. The safest nursing action is to provide support with infant care while assessing the mother’s mood, coping, sleep, and bonding, and screening for warning signs of postpartum depression/psychosis (e.g., persistent severe symptoms, suicidal or infanticidal thoughts, hallucinations). Immediate psychiatry notification is not indicated for simple fatigue without red-flag symptoms, and removing the infant permanently or ignoring the concern is unsafe and non-therapeutic.

Question 43

A client with placenta previa presents at 37 weeks with painless bright red bleeding. FHR is normal. What is the appropriate nursing action?

Accepted Answer

Answer reason: Placenta previa classically causes painless, bright red third-trimester bleeding and is a contraindication to digital vaginal examination due to risk of precipitating massive hemorrhage. At 37 weeks with ongoing bleeding, delivery is typically by cesarean section because the placenta obstructs the cervical os and vaginal delivery can be dangerous. Oxytocin and attempting vaginal delivery are inappropriate because of the obstruction and hemorrhage risk. The priority nursing action is to anticipate and prepare for C-section while maintaining maternal-fetal monitoring and readiness for hemorrhage management.

Question 44

Breast Engorgement Management A postpartum client who is not breastfeeding has breast engorgement. What is the best nursing advice?

Accepted Answer

Answer reason: For a postpartum client who is not breastfeeding, the goal is to suppress lactation and reduce edema and pain. Cold packs decrease swelling and milk production, and a supportive/snug bra provides comfort and helps limit stimulation. Pumping and warm compresses promote milk letdown and can increase production, worsening engorgement. Hormonal suppression is not first-line due to potential adverse effects and is generally avoided for routine lactation suppression.

Question 45

Shoulder Dystocia Management A nurse is assisting in the delivery of a term newborn when the fetal head delivers, but the shoulders remain stuck. What is the first nursing action?

Accepted Answer

Answer reason: Shoulder dystocia is an obstetric emergency where the fetal shoulders are impacted after head delivery; the first-line initial intervention is the McRoberts maneuver (hyperflexion of the maternal hips) to straighten the sacrum and widen the pelvic outlet. This maneuver is quick, noninvasive, and often resolves the dystocia without additional instrumentation. Fundal pressure is contraindicated because it can worsen impaction and increase risk of uterine rupture and neonatal brachial plexus injury. Forceps and increasing oxytocin are not first actions and do not address the mechanical obstruction.

Question 46

A client with gestational diabetes at 38 weeks is in labor. Which fetal complication should the nurse anticipate?

Accepted Answer

Answer reason: Infants of mothers with gestational diabetes are at high risk for neonatal hypoglycemia shortly after birth. Maternal hyperglycemia leads to fetal hyperinsulinemia; when the maternal glucose supply is interrupted at delivery, the newborn’s insulin remains elevated and blood glucose drops. This is a common, anticipated complication and is why early feeding and glucose monitoring are prioritized. The other options are not the most characteristic immediate neonatal complication of maternal diabetes in labor.

Question 47

A nurse is caring for a client who is in labor and has a breech presentation. The nurse knows that this client is at increased risk of which complication?

Accepted Answer

Answer reason: Breech presentation increases the risk of umbilical cord prolapse because the presenting part may not effectively fill and seal the cervical opening, allowing the cord to slip past after rupture of membranes. Cord prolapse can quickly compromise fetal oxygenation due to cord compression between the fetus and maternal pelvis. Placenta previa is related to placental implantation location, shoulder dystocia is classically associated with cephalic delivery and macrosomia, and postpartum hemorrhage is not the primary hallmark complication of breech presentation.

Question 48

Post-partum women having bleeding after 24 hours of the delivery is called as?

Accepted Answer

Answer reason: Postpartum hemorrhage is classified by timing: primary (early) PPH occurs within the first 24 hours after delivery, while secondary (late) PPH occurs after 24 hours up to about 6–12 weeks postpartum. Because the bleeding is specified as occurring after 24 hours, it fits the definition of secondary PPH. “Third stage hemorrhage” refers to hemorrhage during placental delivery (third stage of labor), and “true postpartum hemorrhage” is not a standard timing-based classification term.

Question 49

Nurse Chen is instructing a new mother on breastfeeding practices. Which statement from the client suggests a need for further education?

Accepted Answer

Answer reason: Lactating clients should maintain adequate hydration to support milk production and maternal well-being; four glasses of fluid in 24 hours is typically insufficient. General guidance is to drink enough fluids to satisfy thirst and to increase intake compared with non-lactating needs. The other statements reflect common breastfeeding self-care: wearing a supportive bra, expressing milk when needed to maintain supply/relieve fullness, and allowing warm shower water over the breasts for comfort and letdown.

Question 50

Which dietary recommendation is most appropriate for a client with gestational diabetes mellitus (GDM)?

Accepted Answer

Answer reason: Gestational diabetes nutrition focuses on stabilizing blood glucose by distributing carbohydrates throughout the day and pairing them with protein to blunt postprandial glucose spikes. Small, frequent meals using complex carbohydrates (higher fiber, slower absorption) with protein supports more consistent glycemic control. Increasing overall carbohydrates can worsen hyperglycemia, eliminating all carbohydrates is unsafe/unrealistic in pregnancy, and eating only when hungry can lead to inconsistent intake and glycemic variability.

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

Ante-Intra-Postpartum Care NCLEX Practice Test

Continue Learning