Question 1

Stages of Labor Which statement by a laboring client indicates she is in transition phase of labor?

Accepted Answer

Answer reason: The transition phase (late first stage) is characterized by very strong, frequent contractions and a strong urge to bear down as the presenting part descends and the cervix approaches full dilation. A statement of needing to push is a classic indicator the client is in transition/approaching second stage. Being able to talk through contractions or having mild, irregular contractions suggests early labor, not transition. Social, excited conversation is also more consistent with earlier labor when discomfort is less intense.
Category reason: This item tests recognition of labor stage findings during intrapartum care, which is a core nursing focus in ante-, intra-, and postpartum management rather than basic anatomy/physiology alone.

Question 2

A 30-year-old woman at 12 weeks gestation reports frequent urination and fatigue. What should the nurse prioritize during education?

Accepted Answer

Answer reason: At 12 weeks’ gestation, urinary frequency and fatigue are common physiologic changes related to increased renal perfusion, hormonal effects, and expanding uterine size. Kegel exercises strengthen the pelvic floor and can help prevent or reduce urinary incontinence during pregnancy and postpartum, making them an appropriate educational priority. Reducing fluids is not recommended because pregnancy increases hydration needs and limiting fluids can contribute to dehydration and constipation. Urinary frequency alone is expected in early pregnancy, and while limiting caffeine may help bladder irritation, “avoid all caffeine” is unnecessarily absolute and less central than pelvic floor strengthening.
Category reason: This question focuses on teaching a pregnant client about expected physiologic changes and appropriate self-care during pregnancy, which aligns with antepartum nursing education.

Question 3

A pregnant woman at 16 weeks is worried because she hasn't felt fetal movement. What is the nurse's best response?

Accepted Answer

Answer reason: Quickening (first perceived fetal movement) is typically felt around 18–20 weeks in primigravidas, and may be felt earlier (about 16–18 weeks) in multiparas. At 16 weeks, not feeling fetal movement can be normal, so the most therapeutic and accurate response is reassurance with teaching about expected timing. The other options either provide incorrect information, create unnecessary anxiety, or jump to interventions without assessment findings.
Category reason: The question tests pregnancy teaching and anticipatory guidance about normal fetal development/quickening during prenatal care, which fits Ante-Intra-Postpartum Care under Health Promotion and Maintenance.

Question 4

A woman in her first trimester reports nausea in the morning. What is the best dietary advice?

Accepted Answer

Answer reason: First-trimester morning nausea is commonly worsened by an empty stomach and hypoglycemia; eating small, frequent, protein-rich snacks can help maintain stable blood glucose and reduce nausea. A high-protein snack before bed may reduce early-morning symptoms by preventing overnight fasting. Large meals can worsen nausea due to gastric distention, and drinking fluids with meals may increase fullness and nausea. Avoiding all carbohydrates is unnecessary and can impair adequate caloric intake during pregnancy.
Category reason: This is a pregnancy-related symptom management question focused on dietary counseling for first-trimester nausea, which falls under antepartum care within Health Promotion and Maintenance.

Question 5

Which statement by a 24-week pregnant woman needs correction?

Accepted Answer

Answer reason: Regular nightly use of “herbal tea” in pregnancy needs correction because many herbal products are not standardized, may cross the placenta, and some have uterotonic or other fetal/maternal effects. Pregnant clients should be taught to avoid routine use of herbal remedies unless specifically approved by their prenatal provider. The other statements reflect recommended pregnancy health behaviors: left-side sleeping can improve uteroplacental perfusion, placing the lap belt under the abdomen is correct, and moderate exercise such as walking 30 minutes daily is generally encouraged if no contraindications exist.
Category reason: This item tests prenatal teaching and evaluation of safe health practices during the second trimester, which fits Ante-Intra-Postpartum Care within Health Promotion and Maintenance.

Question 6

Postpartum Hemorrhage Risk Factors Which client is at highest risk for postpartum hemorrhage?

Accepted Answer

Answer reason: Postpartum hemorrhage is most commonly caused by uterine atony. Prolonged labor can fatigue the uterine muscle, and prolonged or high-dose oxytocin exposure may lead to receptor desensitization and reduced uterine contractility after delivery—both increasing atony risk. The other options are less strongly associated with uterine atony compared with prolonged labor plus oxytocin use, making this client the highest risk among those listed.
Category reason: This question tests identification of obstetric/postpartum risk factors to anticipate and prevent complications after birth, which aligns with nursing care in the antepartum/intrapartum/postpartum period.

Question 7

A Rh-negative mother delivers an Rh-positive baby. What nursing intervention is necessary?

Accepted Answer

Answer reason: After delivery of an Rh-positive infant, an Rh-negative mother is at risk for sensitization from fetal Rh-positive red blood cells entering her circulation. Administering Rho(D) immune globulin (RhoGAM) within 72 hours prevents maternal anti-D antibody formation and protects future pregnancies from hemolytic disease of the fetus/newborn. Monitoring the newborn for hyperbilirubinemia is important but does not prevent maternal sensitization. Education and routine postpartum bonding measures are appropriate but are not the critical required preventive intervention.
Category reason: This question asks for a postpartum nursing intervention to prevent Rh isoimmunization after delivery, which is part of antepartum/intrapartum/postpartum care and pregnancy-related health maintenance.

Question 8

A nurse observes a postpartum woman holding the baby loosely, avoiding eye contact. What does this suggest?

Accepted Answer

Answer reason: In the immediate postpartum period, avoiding eye contact with the infant and holding the baby loosely are classic cues of impaired bonding/attachment. Adequate maternal attachment is typically demonstrated by affectionate touch, attentive gaze, and interest in the infant’s cues. Infant hyperactivity is not assessed through the mother’s interaction behaviors. While culture can influence eye contact, the overall pattern described most strongly indicates delayed bonding that warrants further assessment and supportive interventions.
Category reason: This item tests recognition of maternal-infant attachment behaviors and complications in the postpartum period, which falls under antepartum/intrapartum/postpartum nursing care.

Question 9

Women in their 30s and 40s can have healthy pregnancies, but are at increased risk of which condition?

Accepted Answer

Answer reason: Advanced maternal age (commonly ≥35 years) is associated with increased risk of gestational diabetes due to greater baseline insulin resistance and higher prevalence of metabolic risk factors. It is also associated with higher rates of hypertensive disorders of pregnancy (chronic hypertension and preeclampsia) compared with younger pregnant patients. Chronic fatigue syndrome is not a typical age-related pregnancy risk factor. Therefore, both diabetes and hypertension are increased risks.
Category reason: The question focuses on age-related pregnancy risks and maternal complications during pregnancy, which aligns with ante-, intra-, and postpartum care in Health Promotion and Maintenance.

Question 10

Which of the following medications is safe for managing nausea and vomiting in pregnancy?

Accepted Answer

Answer reason: First-line pharmacologic treatment for nausea and vomiting of pregnancy is pyridoxine (vitamin B6), often used alone or combined with doxylamine due to a strong safety record in pregnancy. Ondansetron, metoclopramide, and promethazine may be used when symptoms are refractory, but they are generally considered second-line because of comparatively greater concern for adverse effects and less favorable first-line safety/experience. Therefore, the safest best answer among the listed options is pyridoxine.
Category reason: The question tests safe medication selection for a common pregnancy symptom (nausea/vomiting), which is part of nursing care during pregnancy and therefore falls under Ante-Intra-Postpartum Care.

Question 11

A client in the second stage of labor is experiencing weak, irregular contractions and is unable to bear down effectively. Which of the 5 P's is currently limiting the progress of this labor?

Accepted Answer

Answer reason: The 5 P’s include power (uterine contractions and maternal pushing), passenger, passageway, position, and psyche. Weak, irregular contractions plus ineffective bearing down indicate inadequate expulsive forces, which directly reflects a problem with power. The other options (fetal position/passenger and maternal pelvis/passageway) are not supported by the stem because the limiting issue described is the strength/regularity of contractions and pushing effort.
Category reason: The question tests intrapartum nursing assessment of labor progress using the 5 P’s framework, which is part of ante-, intra-, and postpartum care in Health Promotion and Maintenance.

Question 12

The first fetal heart sounds can typically be heard by Doppler at?

Accepted Answer

Answer reason: With a handheld Doppler, fetal heart tones are typically detectable near the end of the first trimester, most commonly around 10–12 weeks of gestation. Earlier detection (around 6–7 weeks) is generally possible with transvaginal ultrasound rather than Doppler auscultation. Because the question asks what can typically be heard by Doppler, 12 weeks is the best single answer among the options. This timing reflects the increasing fetal size and stronger cardiac activity that becomes audible through the maternal abdominal wall.
Category reason: This question tests prenatal assessment timing (when fetal heart tones are first heard with Doppler) as part of routine antepartum care, which aligns with Health Promotion and Maintenance in Ante-Intra-Postpartum Care.

Question 13

Exclusive breastfeeding is recommended for how many months?

Accepted Answer

Answer reason: Major health organizations (e.g., WHO and AAP) recommend exclusive breastfeeding for about the first 6 months of life, meaning no other foods or liquids except medicines/vitamins when indicated. This provides optimal nutrition and passive immunity, and it reduces risks of common infant infections. After 6 months, complementary foods are introduced while breastfeeding is continued as desired.
Category reason: The question tests a health-promotion guideline for infant feeding during early life, which is part of maternal-newborn/infant care education addressed in ante-, intra-, and postpartum nursing.

Question 14

After the expulsion of the placenta in a client who has six living children, an infusion of lactated ringer’s solution with 10 units of Pitocin is ordered. The nurse understands that this is indicated for this client because?

Accepted Answer

Answer reason: Oxytocin (Pitocin) is routinely administered after placental delivery to promote uterine contraction and prevent postpartum hemorrhage. Grand multiparity (six living children) increases the risk of uterine overdistention and decreased uterine tone, leading to uterine atony. Therefore, prophylactic Pitocin in IV fluids is indicated to maintain uterine firmness. The other options are not the primary indication for postpartum oxytocin administration after placental expulsion.
Category reason: The question focuses on a postpartum nursing intervention (administering Pitocin after delivery) and the clinical rationale to prevent a complication (uterine atony/postpartum hemorrhage), which is part of antepartum-intrapartum-postpartum care.

Question 15

What is the purpose of Leopold’s maneuvers?

Accepted Answer

Answer reason: Leopold’s maneuvers are a series of abdominal palpation techniques used to identify the fetus’s lie (longitudinal/transverse), presentation (cephalic/breech), and position by locating the fetal back and extremities. This helps guide assessment such as optimal placement for auscultating fetal heart tones and anticipating potential labor complications. They do not directly measure fetal heart rate, evaluate contraction strength/frequency, or assess cervical dilation (which requires vaginal examination).
Category reason: The question tests an antenatal/intrapartum nursing assessment technique used in pregnancy to evaluate fetal position and presentation, which aligns with ante-intra-postpartum care.

Question 16

The total number of foetal and early neonatal deaths per 1000 live births is called?

Accepted Answer

Answer reason: Perinatal mortality rate includes both late fetal deaths (stillbirths) and early neonatal deaths, commonly expressed per 1000 total births (or per 1000 live births depending on the definition used). The question specifically asks for the combined total of fetal and early neonatal deaths, which matches the concept of perinatal mortality. The other options describe only one component (fetal/intrauterine death or neonatal death) rather than the combined measure.
Category reason: This item tests an obstetric/newborn public health indicator used in antepartum/intrapartum/postpartum and newborn outcome monitoring rather than body-system science mechanisms, fitting Ante-Intra-Postpartum Care.

Question 17

A nurse is caring for a client who is experiencing postpartum hemorrhage as a result of uterine atony. The nurse understands this means that?

Accepted Answer

Answer reason: Uterine atony is the failure of the uterus to contract effectively after delivery, which prevents compression of uterine blood vessels and leads to postpartum hemorrhage. A uterine tear describes laceration/rupture rather than atony. Retained placental fragments can cause hemorrhage, but that is a different etiology than uterine atony. Excessive contraction is the opposite of atony and would not explain bleeding from poor uterine tone.
Category reason: This item tests recognition of a common postpartum complication (postpartum hemorrhage due to uterine atony) and its meaning in the context of maternal care after delivery, which fits Ante-Intra-Postpartum Care.

Question 18

The nurse suspects abruptio placentae. Which symptom supports this?

Accepted Answer

Answer reason: Abruptio placentae typically presents with painful vaginal bleeding and a tender, firm/rigid “board-like” uterus due to concealed or revealed hemorrhage and uterine irritability. Uterine rigidity and pain are therefore key supporting symptoms. In contrast, painless bleeding is more consistent with placenta previa. Normal fetal heart rate and a soft abdomen do not support placental abruption, which often compromises fetal oxygenation and increases uterine tone.
Category reason: This item tests recognition of an obstetric complication during pregnancy and its characteristic maternal findings, which falls under antepartum/intrapartum nursing care.

Question 19

When does quickening usually occur in primigravida?

Accepted Answer

Answer reason: Quickening is the first maternal perception of fetal movement. In a primigravida, it is typically felt later than in a multigravida because the sensation is unfamiliar and the uterine/abdominal wall has not been previously stretched. The usual timing is around 18–20 weeks’ gestation, whereas multiparous clients may perceive it earlier (about 16–18 weeks). Therefore, 18–20 weeks is the best answer.
Category reason: The question tests normal pregnancy milestones (timing of quickening) used in antenatal assessment and client education, which fits antepartum care under Health Promotion and Maintenance.

Question 20

Which of the following is a maternal benefit of breastfeeding?

Accepted Answer

Answer reason: Breastfeeding is associated with a decreased lifetime risk of breast cancer, likely due to reduced lifetime estrogen exposure and breast tissue differentiation during lactation. In contrast, breastfeeding promotes uterine involution via oxytocin release and typically decreases postpartum bleeding. It is also associated with a reduced risk of type 2 diabetes in mothers rather than an increased risk. Therefore, the correct maternal benefit listed is a lower risk of breast cancer.
Category reason: The question tests maternal health education about breastfeeding effects during the postpartum period, which falls under antepartum/intrapartum/postpartum care in Health Promotion and Maintenance.

Question 21

What correctly matches the type of deceleration with its likely cause?

Accepted Answer

Answer reason:Late decelerations occur after the peak of a contraction and indicate decreased uteroplacental perfusion, resulting in fetal hypoxia. This pattern is classically associated with uteroplacental insufficiency.
Category reason:Fetal heart rate monitoring and interpretation of deceleration patterns are core components of intrapartum assessment and management.

Question 22

A nurse is caring for a client in active labor with late decelerations on the fetal monitor. What is the priority nursing intervention?

Accepted Answer

Answer reason: Late decelerations indicate uteroplacental insufficiency and possible fetal hypoxia, so the first priority is to improve uteroplacental blood flow and oxygen delivery. Repositioning to the left lateral position relieves aortocaval compression, increases maternal cardiac output, and can improve placental perfusion. Increasing oxytocin can worsen uterine tachysystole and fetal hypoxia, while fundal pressure and bearing down can further compromise fetal oxygenation and are not priority interventions for late decelerations.
Category reason: The item tests intrapartum nursing assessment and immediate intervention for abnormal fetal heart rate patterns during labor, which falls under ante-, intra-, and postpartum care in Health Promotion and Maintenance.

Question 23

The most common cause of nipple pain in breastfeeding mothers is?

Accepted Answer

Answer reason: The most common cause of nipple pain during breastfeeding is an improper latch, which leads to excessive friction and compression of the nipple rather than the baby taking a deep mouthful of areola. Poor latch commonly results in nipple trauma (cracking, blanching, burning pain) and is typically worse at the start of feeds. Engorgement, plugged ducts, and mastitis can cause breast pain/tenderness, but they are less common as the primary cause of nipple pain compared with latch problems. Correcting positioning and achieving a deep latch usually relieves symptoms quickly.
Category reason: This question centers on breastfeeding assessment and management in the postpartum period, which is part of maternal-newborn care and health promotion guidance provided by nurses.

Question 24

The danger sign in pregnancy that may indicate pre-eclampsia is?

Accepted Answer

Answer reason: Blurred vision is a warning sign of preeclampsia due to cerebral/retinal vasospasm and evolving severe features, and it requires urgent evaluation. While edema (swelling of feet) and weight gain can occur in pregnancy and may be seen with preeclampsia, they are less specific and can be normal findings. Nausea is common in pregnancy and is not a classic danger sign for preeclampsia. Therefore, blurred vision is the best indicator among the options.
Category reason: The question tests recognition of a pregnancy danger sign requiring maternal assessment and escalation of care, which is part of antepartum/intrapartum/postpartum nursing care.

Question 25

A client with preeclampsia develops hyperreflexia and clonus, and the nurse notes a respiratory rate of 14 breaths per minute. The nurse understands that these findings indicate:

Accepted Answer

Answer reason: Hyperreflexia and clonus in a client with preeclampsia are signs of neuromuscular irritability and worsening disease, indicating increased risk for progression to seizures (eclampsia). A respiratory rate of 14/min is within normal range and does not suggest magnesium sulfate toxicity, which typically presents with diminished/absent deep tendon reflexes and respiratory depression (often

Question 26

The nurse understands that the fetal head is in which of the following positions with a face presentation?

Accepted Answer

Answer reason: In a face presentation, the fetal head is hyperextended so that the face (rather than the occiput or brow) is the presenting part. Complete extension allows the mentum (chin) to be the key landmark for assessing position and feasibility of vaginal delivery. Partial extension corresponds more to brow presentation, and flexion corresponds to vertex presentations. Therefore, the correct position of the fetal head in face presentation is completely extended.
Category reason: This question tests intrapartum obstetric knowledge about fetal presentations and how the nurse assesses labor, which falls under antepartum/intrapartum/postpartum care in Health Promotion and Maintenance.

Question 27

Using Naegele’s Rule, calculate the estimated date of birth for a client who reports the first day of the last menstrual period was August 7.?

Accepted Answer

Answer reason: Naegele’s rule estimates the due date by adding 7 days to the first day of the last menstrual period (LMP), subtracting 3 months, and adding 1 year. Starting with August 7: add 7 days to get August 14, then subtract 3 months to get May 14, then add 1 year (year not specified in the question). Therefore, the best answer is May 14.
Category reason: This is an obstetric dating question using Naegele’s rule to estimate expected date of delivery from the LMP, which is part of antepartum care in Health Promotion and Maintenance.

Question 28

Case: A 27-year-old G1P0 woman in active labor receives an epidural. Thirty minutes later, her BP is 78/44 mmHg and she reports nausea. What is the nurse’s priority action?

Accepted Answer

Answer reason: The patient has acute hypotension and nausea shortly after epidural placement, consistent with sympathetic blockade causing vasodilation and decreased venous return. The immediate nursing priority is to improve maternal perfusion (and therefore uteroplacental blood flow) by left lateral positioning to relieve aortocaval compression and by increasing IV fluids to expand intravascular volume. Discontinuing the epidural may be considered later, but first-line stabilization is positioning and fluids; placing her supine can worsen hypotension. There is no information suggesting an emergent cesarean is indicated as the initial action.
Category reason: This item tests intrapartum nursing recognition and immediate interventions for a common epidural complication (maternal hypotension) to protect maternal-fetal perfusion, which fits Ante-Intra-Postpartum Care.

Question 29

Greenish yellow amniotic fluid indicates:- ????

Accepted Answer

Answer reason: Greenish-yellow (meconium-stained) amniotic fluid typically indicates passage of meconium in utero, most commonly associated with fetal hypoxia/stress. Fetal distress can stimulate vagal response and intestinal peristalsis with relaxation of the anal sphincter, leading to meconium in the fluid. This finding raises concern for fetal compromise and risk of meconium aspiration, prompting closer fetal monitoring and readiness for neonatal airway support. The other options do not classically produce greenish-yellow staining of amniotic fluid.
Category reason: The item tests recognition of an intrapartum obstetric sign (meconium-stained amniotic fluid) and its implication for maternal-fetal care during labor and delivery, which fits Ante-Intra-Postpartum Care.

Question 30

Fetal movement can be felt by the mother...?

Accepted Answer

Answer reason: Maternal perception of fetal movement (quickening) is typically first felt at about 16–20 weeks of gestation. Primigravidas often perceive movement closer to 18–20 weeks, while multigravidas may notice it earlier (around 16 weeks). It is generally not felt in the first trimester, and waiting until late third trimester would be inconsistent with normal fetal development and expected maternal findings.
Category reason: This question tests normal prenatal milestone timing (quickening) during pregnancy, which falls under antepartum care and expected findings taught in maternity nursing.

Question 31

Which of the following is a key symptom and sign of preeclampsia?

Accepted Answer

Answer reason: Preeclampsia is classically characterized by new-onset hypertension after 20 weeks of gestation with evidence of end-organ involvement, commonly proteinuria. The combination of elevated blood pressure and protein in the urine is therefore a key sign suggesting preeclampsia. The other options describe findings more consistent with dehydration/illness or metabolic states and are not defining features of preeclampsia. Recognizing these hallmark findings is crucial to prevent progression to severe preeclampsia or eclampsia.
Category reason: The question tests recognition of a major pregnancy complication and its hallmark clinical findings, which falls under nursing care and assessment during pregnancy (antepartum).

Question 32

The nurse is collecting data from a pregnant client who is at 28 weeks' gestation. The nurse measures the fundal height in centimeters and should expect which finding?

Accepted Answer

Answer reason:  28 cm. From about 20 to 36 weeks of gestation, fundal height in centimeters generally correlates with gestational age in weeks (±2 cm). At 28 weeks, an expected fundal height is therefore approximately 28 cm. A measurement like 22 cm would suggest the uterus is smaller than expected (e.g., inaccurate dating or growth restriction), while 36–40 cm would be larger than expected (e.g., polyhydramnios, multiple gestation, or macrosomia) and warrants further evaluation.
Category reason: This question tests a routine prenatal assessment (expected fundal height by gestational age) used by nurses when collecting antepartum data, fitting Health Promotion and Maintenance: Ante-Intra-Postpartum Care.

Question 33

The pregnant client has a nonreactive result to a nonstress test. The same client undergoes a contraction stress test and receives a negative result. The nurse knows this would be documented as?

Accepted Answer

Answer reason:  Normal. A negative contraction stress test (no late decelerations with contractions) indicates adequate uteroplacental perfusion and is considered a reassuring/normal finding. A nonreactive nonstress test can occur for benign reasons (e.g., fetal sleep cycle) and often prompts further testing rather than confirming compromise. When follow-up CST is negative, fetal status is overall reassuring and would be documented as normal rather than abnormal or requiring immediate delivery.
Category reason: This question tests interpretation of antepartum fetal surveillance (NST and contraction stress test) and appropriate nursing documentation of results, which falls under Ante-Intra-Postpartum Care.

Question 34

What is the most common early symptom of pregnancy?

Accepted Answer

Answer reason: Missed Period Amenorrhea (a missed menstrual period) is one of the earliest and most common symptoms of pregnancy due to hormonal changes after implantation and rising hCG/progesterone levels. While symptoms like headache or back pain can occur, they are nonspecific and not as reliably early or common as a missed period. Fever is not a normal pregnancy symptom and suggests infection or another condition requiring evaluation.
Category reason: This question tests recognition of an early sign of pregnancy and relates to maternal/obstetric health topics, fitting Ante-Intra-Postpartum Care within Health Promotion and Maintenance.

Question 35

How many times is ultrasound generally recommended during pregnancy?

Accepted Answer

Answer reason: 2-3 times In routine prenatal care for an uncomplicated pregnancy, ultrasound is commonly performed in early pregnancy for dating/viability and again at 18–22 weeks for the anatomic survey, with an additional scan sometimes done for growth or placental assessment. Thus, a general recommendation is about 2–3 ultrasounds across pregnancy, recognizing that high-risk conditions may require more frequent monitoring. Options such as daily or 5–10 times are not typical for low-risk pregnancies, and “once” omits the standard mid-trimester anatomy scan.
Category reason: This question focuses on typical prenatal screening/monitoring practices during pregnancy, which falls under routine ante-, intra-, and postpartum care in Health Promotion and Maintenance.

Question 36

The nurse is caring for a client on the postpartum unit. Upon assessment of the uterus, the nurse notes that it feels 'soft' and 'boggy'. What is the nurse's priority action?

Accepted Answer

Answer reason: Massage fundus until firm. A soft, boggy uterus postpartum indicates uterine atony, the leading cause of postpartum hemorrhage, so the priority is to promote uterine contraction immediately. Fundal massage is an urgent nursing intervention to firm the uterus and reduce bleeding while simultaneously assessing lochia and vital signs. Notifying the PHCP may be needed if massage is ineffective or bleeding persists, but immediate nursing action comes first; assisting to void can help if bladder distention is contributing, but it is not the first priority when uterine tone is already poor.
Category reason: This is a postpartum assessment finding requiring an immediate nursing intervention to prevent hemorrhage, which falls under antepartum/intrapartum/postpartum nursing care.

Question 37

Which food should be avoided during pregnancy?

Accepted Answer

Answer reason: Raw papaya Raw (unripe) papaya contains latex and papain-like enzymes that may stimulate uterine contractions and cervical changes, which is why it is commonly advised to avoid it during pregnancy. In contrast, fresh fruits, milk (pasteurized), and green vegetables are generally encouraged as part of a balanced prenatal diet. Therefore, among the given choices, raw papaya is the best answer to avoid.
Category reason: This is a prenatal nutrition counseling question focused on what foods to avoid to reduce pregnancy-related risk, which aligns with Ante-Intra-Postpartum Care under Health Promotion and Maintenance.

Question 38

A client in active labor reports severe back pain during contractions. The fetus is in the occiput posterior position. What is the priority nursing intervention?

Accepted Answer

Answer reason: Apply counter-pressure to the lower back Occiput posterior positioning commonly causes intense back labor due to fetal skull pressure against the maternal sacrum during contractions. Counter-pressure to the lower back is a first-line, nonpharmacologic comfort intervention that can be initiated immediately and is safe for both mother and fetus. IV opioids may reduce pain but can cause maternal/fetal sedation and are not the most immediate targeted intervention for OP back pain. Emergency cesarean is not indicated solely for OP position with back pain, and frequent urination does not address the primary cause of this pain.
Category reason: This item tests nursing management of a laboring client (comfort measures and intrapartum interventions) related to fetal position, which fits Ante-Intra-Postpartum Care.

Question 39

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

Accepted Answer

Answer reason: After 1-3 minutes Delayed cord clamping for about 1–3 minutes in uncomplicated term births improves placental transfusion, increasing neonatal blood volume and iron stores and reducing risk of infant anemia. Immediate clamping can reduce this transfusion benefit without routine advantage in a normal delivery. Waiting until after placental expulsion is unnecessarily late and not standard practice, and timing is not based on whether the baby cries.
Category reason: This item tests an intrapartum/postpartum nursing practice decision about the timing of umbilical cord clamping during a normal delivery, which fits Ante-Intra-Postpartum Care.

Question 40

During active labor, which of the following fetal heart rate patterns is most concerning and requires immediate intervention?

Accepted Answer

Answer reason: Late decelerations Late decelerations are associated with uteroplacental insufficiency and fetal hypoxia/acidemia, making them the most concerning pattern during active labor. They occur after the peak of the contraction and signal compromised fetal oxygenation, especially if recurrent and accompanied by decreased variability. This pattern typically warrants prompt intrauterine resuscitation (e.g., maternal repositioning, IV fluids, reduce uterine tachysystole, oxygen per protocol) and escalation of care. In contrast, early decelerations are usually benign (head compression), accelerations are reassuring, and variable decelerations are often due to cord compression and may be managed depending on severity and recurrence.
Category reason: This item tests intrapartum fetal monitoring interpretation and the need for urgent action during labor, which is part of nursing care in pregnancy and childbirth (ante/intra/postpartum care).

Question 41

A laboring patient with ruptured membranes suddenly reports sharp abdominal pain, loss of fetal station, and fetal bradycardia. What should the nurse suspect first?

Accepted Answer

Answer reason: Uterine rupture The combination of sudden sharp abdominal pain, loss of fetal station (the presenting part moves back up), and fetal bradycardia is classic for uterine rupture, an obstetric emergency. Rupture can cause fetal distress from acute compromise of uteroplacental perfusion and may be accompanied by abnormal labor progress and maternal hemodynamic instability. Cord prolapse is strongly associated with fetal bradycardia after rupture of membranes but does not explain sudden severe abdominal pain or loss of station as well as uterine rupture. Placental abruption typically presents with painful bleeding and uterine tenderness/rigidity, and shoulder dystocia occurs after delivery of the head rather than presenting with loss of station.
Category reason: This is an intrapartum complication recognition question requiring nursing judgment about an obstetric emergency during labor, which fits Ante-Intra-Postpartum Care.

Question 42

The nurse would be concerned if a client exhibited which of the following symptoms during her postpartum stay?

Accepted Answer

Answer reason: Vaginal discharge or rubra, serosal then rubra Normal lochia progression is rubra (red) for the first several days, then serosa (pink/brown), then alba (white/yellow). Returning from serosa back to rubra (or persistent rubra) can indicate subinvolution, retained products of conception, or postpartum hemorrhage and warrants further assessment. The other findings—relative bradycardia (50–70 bpm), postpartum diuresis, and diaphoresis—are expected physiologic changes as the body eliminates excess fluid from pregnancy.
Category reason: This item tests recognition of expected vs abnormal postpartum findings (lochia pattern and postpartum physiologic changes), which is part of nursing assessment and patient care during the postpartum period.

Question 43

A primipara is being evaluated in the clinic during her second trimester of pregnancy. Which indicates an abnormal physical finding that necessitates further testing?

Accepted Answer

Answer reason: Fetal heart rate of 180 beats per minute. Normal baseline fetal heart rate is typically 110–160 beats/min; 180 indicates fetal tachycardia and warrants further assessment and testing. Potential causes include maternal fever/infection, dehydration, medications, fetal hypoxia, or arrhythmias. In contrast, quickening, Braxton Hicks contractions, and a consistent increase in fundal height are expected/normal findings in the second trimester.
Category reason: This item assesses recognition of normal versus abnormal findings during pregnancy and the need for follow-up evaluation, which aligns with antepartum care in Health Promotion and Maintenance.

Question 44

A woman with preeclampsia is receiving magnesium sulfate. Which indicates to the nurse that the magnesium sulfate therapy is effective?

Accepted Answer

Answer reason: Seizures do not occur. Magnesium sulfate in preeclampsia is primarily used for seizure prophylaxis (preventing progression to eclampsia), so the absence of seizures indicates therapeutic effectiveness. Scotomas and ankle clonus are warning signs of worsening neurologic irritability and do not indicate effective therapy. While blood pressure may be treated with antihypertensives, magnesium sulfate is not administered primarily to lower blood pressure, so a decrease in BP is not the best indicator of magnesium effectiveness.
Category reason: This question tests nursing evaluation of therapy effectiveness for a pregnancy complication (preeclampsia) and appropriate outcome monitoring in the antepartum/intrapartum setting.

Question 45

During which trimester is travelling generally considered safe?

Accepted Answer

Answer reason: 2nd trimester The second trimester (approximately 14–28 weeks) is generally the safest and most comfortable time for travel in an uncomplicated pregnancy. Early pregnancy has higher nausea/fatigue and a higher baseline risk of miscarriage, while late pregnancy has increased risks such as preterm labor, reduced comfort/mobility, and travel restrictions by airlines/cruise lines. Nursing teaching typically emphasizes individualized assessment and provider consultation, but as a general rule the 2nd trimester is preferred.
Category reason: This is about counseling pregnant clients on safe timing of travel, which is an antepartum health-promotion/maintenance topic within maternity care.

Question 46

Which maternal factor may inhibit fetal descent and require further nursing interventions?

Accepted Answer

Answer reason: A full bladder A distended bladder can physically impede engagement and descent of the fetal presenting part by occupying pelvic space and altering the angle of the pelvis. It may also contribute to dysfunctional labor patterns and increased discomfort. Nursing interventions include encouraging voiding at least every 2 hours, assisting to the bathroom/bedpan, or catheterization per protocol if the client cannot void.
Category reason: This question tests intrapartum nursing assessment and interventions that affect labor progress (fetal descent), which falls under Ante-Intra-Postpartum Care.

Question 47

What is a normal weight gain for a woman with normal BMI during pregnancy?

Accepted Answer

Answer reason: 25-35 lbs For a singleton pregnancy with a pre-pregnancy normal BMI (18.5–24.9), the Institute of Medicine guideline recommends a total gestational weight gain of 25–35 lb. This range supports appropriate fetal growth while limiting risks such as gestational hypertension, cesarean birth, macrosomia, and postpartum weight retention. The other options are either far below recommended gain (risking growth restriction) or excessively high (increasing maternal-fetal complications).
Category reason: This question tests prenatal health counseling about recommended gestational weight gain based on pre-pregnancy BMI, which is part of routine antepartum care and health promotion in pregnancy.

Question 48

Postpartum Hemorrhage Which of the following nursing interventions is the priority in managing postpartum hemorrhage?

Accepted Answer

Answer reason: Massage the fundus until firm Postpartum hemorrhage is most commonly caused by uterine atony, and immediate fundal massage promotes uterine contraction to compress uterine vessels and reduce bleeding. This is a rapid, nurse-initiated action that can be done immediately while additional interventions are obtained. Oxytocin is also appropriate but requires an order/prescription and is typically initiated after or alongside immediate uterine massage. Vital signs monitoring is important for detecting shock but does not directly stop the hemorrhage, and breastfeeding is not an acute priority during active hemorrhage.
Category reason: This item tests nursing management of an obstetric emergency (postpartum hemorrhage) and prioritization of immediate postpartum interventions, which fits Ante-Intra-Postpartum Care.

Question 49

The physician ordered Betamethasone to a pregnant woman at 34 weeks of gestation with sign of preterm labor. The nurse expects that the drug will?

Accepted Answer

Answer reason: Stimulate the production of surfactant. Betamethasone is an antenatal corticosteroid given when preterm birth is threatened to accelerate fetal lung maturation. It increases fetal surfactant production and improves lung compliance, reducing neonatal respiratory distress syndrome and related complications (e.g., intraventricular hemorrhage). It is not used to treat infection, and it does not directly stop contractions (that is the role of tocolytics). It also does not reduce maternal hypertension risk and can transiently increase blood glucose.
Category reason: This item tests nursing understanding of an obstetric medication’s purpose and expected maternal-fetal outcome in threatened preterm labor, which is antepartum care decision-making.

Question 50

A client has noticed her nipples are enlarging and getting darker pigmented. What type of pregnancy symptom is this?

Accepted Answer

Answer reason: A. Presumptive Nipple/areolar enlargement and darkening are subjective changes typically noticed and reported by the client, so they are classified as presumptive signs of pregnancy. Presumptive signs suggest pregnancy but are not diagnostic because they can occur with hormonal changes unrelated to pregnancy. Probable signs are objective findings (e.g., positive urine test, Hegar sign), and positive signs are definitive evidence (e.g., fetal heart tones, ultrasound).
Category reason: This item tests recognition of pregnancy sign categories (presumptive/probable/positive) in the context of maternal assessment, which fits Ante-Intra-Postpartum Care.

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

Ante-Intra-Postpartum Care NCLEX Practice Test

Continue Learning