Question 1

You performed Leopold’s maneuver and found the following: breech presentation, fetal back at the right side of the mother. Based on these findings, you can hear the fetal heart beat (PMI) BEST in which location?

Accepted Answer

Answer reason: Right upper quadrant In breech presentation, the fetal heart tones are best heard above the maternal umbilicus because the fetal chest is positioned higher in the uterus. The PMI is also heard best on the same side as the fetal back, since the back transmits heart sounds most clearly. With the fetal back on the mother’s right side and a breech presentation, the optimal auscultation point is the right upper quadrant.
Category reason: This question tests a prenatal assessment skill (locating fetal heart tones using Leopold’s maneuvers and fetal position), which is part of routine antepartum/intrapartum nursing care.

Question 2

Which of the following is a common complication during pregnancy?

Accepted Answer

Answer reason: Gestational diabetes Gestational diabetes mellitus is a common pregnancy complication caused by pregnancy-related insulin resistance, typically screened for at 24–28 weeks’ gestation. It increases risks for maternal complications (e.g., hypertensive disorders) and fetal/neonatal complications (e.g., macrosomia, neonatal hypoglycemia). Low blood pressure can occur physiologically but is not typically categorized as a major complication, and migraine/asthma are preexisting conditions that may fluctuate rather than being common pregnancy-specific complications.
Category reason: This item tests knowledge of a common pregnancy-specific complication and routine prenatal screening considerations, which falls under ante-, intra-, and postpartum care in Health Promotion and Maintenance.

Question 3

At how many weeks of pregnancy can fetal heart sounds usually be detected by Doppler?

Accepted Answer

Answer reason: 10–12 weeks Fetal heart tones are typically detected with a handheld Doppler around 10–12 weeks’ gestation in routine clinical practice. Earlier detection (e.g., 6–7 weeks) is more consistent with transvaginal ultrasound visualization of cardiac activity rather than Doppler auscultation. Later detection (18–20 weeks) aligns more with fetoscope use, not Doppler, and would be unusually late for Doppler detection.
Category reason: This question tests prenatal assessment timing (when fetal heart tones are detectable with Doppler), which is a standard antepartum care concept within Growth and Development.

Question 4

How many doses of T.T. are given during the first pregnancy?

Accepted Answer

Answer reason: 2 In routine antenatal care for a first pregnancy with no prior tetanus immunization, two doses of tetanus toxoid (often as Td/Tdap depending on guidelines) are given during pregnancy to provide primary protection. The doses are typically spaced at least 4 weeks apart, with the first given as early as possible and the second later in pregnancy. This schedule helps prevent maternal and neonatal tetanus by ensuring adequate antibody production and transplacental transfer to the fetus.
Category reason: This item tests antenatal immunization scheduling in pregnancy, which is part of routine antepartum care and preventive maternal-newborn health management.

Question 5

A nurse is caring for a postpartum client. Which finding would make the nurse suspect endometritis in this client?

Accepted Answer

Answer reason: Fever over 38 C, beginning 2 days postpartum Postpartum endometritis typically presents with uterine infection signs, most notably fever (often >38°C) developing after the first 24 hours postpartum, commonly around day 2–3. Breast engorgement can cause mild temperature elevation but is usually associated with breast tenderness and occurs around milk coming in, not a persistent postpartum fever pattern. Elevated WBC count is common physiologically in the postpartum period and is not specific for infection. Lochia rubra on postpartum day 2 is a normal expected finding.
Category reason: This item tests recognition of an abnormal postpartum assessment finding (postpartum fever pattern suggesting uterine infection) and the nurse’s clinical judgment in the ante/postpartum period, which fits Ante-Intra-Postpartum Care.

Question 6

The client is undergoing an amniocentesis at 16 weeks' gestation to detect the presence of biochemical or chromosomal abnormalities. Which instructions should the nurse reinforce to the client?

Accepted Answer

Answer reason: The bladder must be empty during the exam. For a second-trimester (about 16 weeks) amniocentesis, the client is typically instructed to empty the bladder to reduce risk of bladder puncture and to facilitate safe needle placement under ultrasound guidance. A full bladder is more relevant to early pregnancy ultrasound imaging, not mid-trimester amniocentesis. RhoGAM is indicated for Rh-negative clients after potentially sensitizing procedures, not Rh-positive clients. Routine NPO status is not generally required for standard amniocentesis unless specific sedation/anesthesia is planned.
Category reason: This question tests nursing teaching for a prenatal diagnostic procedure (amniocentesis) during pregnancy, which fits antepartum care education and preparation.

Question 7

The nursing instructor asks a nursing student to describe the process of quickening. Which statement indicates an understanding of this term?

Accepted Answer

Answer reason: It is the fetal movement that is felt by the mother. Quickening refers to the first perception of fetal movement by the pregnant person, typically felt during the second trimester. The other options describe different pregnancy findings: compressibility of the lower uterine segment is Hegar sign, irregular painless contractions are Braxton Hicks contractions, and a soft blowing sound on auscultation is a uterine soufflé. Therefore, fetal movement felt by the mother is the correct definition.
Category reason: This item tests understanding of a normal pregnancy milestone (quickening) and differentiating it from other antepartum assessment findings, which fits Ante-Intra-Postpartum Care.

Question 8

True or False Fetal heart rate between 110–160 bpm is considered normal.?

Accepted Answer

Answer reason: True A normal baseline fetal heart rate is typically 110–160 beats per minute. Rates below 110 suggest fetal bradycardia and rates above 160 suggest tachycardia, which can indicate fetal distress or maternal/fetal factors requiring assessment. Therefore, the statement correctly describes the standard normal range used in obstetric monitoring.
Category reason: This item tests knowledge of normal fetal assessment parameters used during pregnancy/labor, which fits Ante-Intra-Postpartum Care under Growth and Development.

Question 9

During a non-stress test, a 33-week fetus has two accelerations of 15 bpm lasting 20 seconds in 20 minutes. How is this interpreted?

Accepted Answer

Answer reason: Reactive At ≥32 weeks gestation, a reactive NST requires at least two fetal heart rate accelerations of ≥15 bpm above baseline lasting ≥15 seconds within a 20-minute window. This fetus has two accelerations of 15 bpm lasting 20 seconds in 20 minutes, meeting the criteria. A reactive NST is reassuring and suggests adequate fetal oxygenation and intact autonomic function.
Category reason: This question tests interpretation of a prenatal fetal surveillance test (non-stress test) and its implications in pregnancy, which is part of antepartum/intrapartum obstetric nursing care.

Question 10

Which position would be most beneficial for promoting fetal descent and cervical effacement during the first stage of labor?

Accepted Answer

Answer reason: Standing or walking Upright positioning uses gravity to facilitate fetal descent and increases pelvic diameters, which can enhance cervical effacement and dilation during the first stage of labor. Ambulation also promotes more effective uterine contractions and can improve maternal comfort. Supine and lithotomy positions can reduce uteroplacental perfusion via aortocaval compression and are less favorable for descent compared with upright mobility. Side-lying can be helpful for rest and circulation but generally does not promote descent as effectively as upright ambulation.
Category reason: This item asks about a labor-management intervention (maternal positioning) to promote progression of labor, which is part of nursing care during the intrapartum period.

Question 11

The nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The nurse notes that the health care provider has documented the presence of Goodell's sign. The nurse determines that this sign is indicative of which?

Accepted Answer

Answer reason: A. A softening of the cervix. Goodell's sign refers to softening of the cervix due to increased vascularity and edema in early pregnancy and is considered a probable sign of pregnancy. Fetal movement is a positive sign only when confirmed by an examiner, not simply reported. hCG in urine explains a positive pregnancy test, not Goodell’s sign. The soft blowing sound synchronous with the maternal pulse is the uterine souffle, a different finding.
Category reason: This question tests recognition of a pregnancy-related physical assessment finding (Goodell’s sign) and its meaning in early pregnancy, which falls under antepartum care and maternal assessment.

Question 12

What is the most important thing to pack in a hospital bag for delivery?

Accepted Answer

Answer reason: Baby clothes and diapers For a delivery hospital bag, essentials center on postpartum and newborn immediate needs. Baby clothing and diapers support basic newborn care and comfort after birth and for discharge planning. The other options are nonessential and do not address maternal-newborn care priorities during admission.
Category reason: This question focuses on preparation for childbirth and immediate newborn needs, aligning with antepartum/intrapartum/postpartum education and care planning.

Question 13

The client at 28 weeks' gestation is Rh negative and Coombs antibody negative. The nurse determines that the client understands what the nurse has taught her about Rh sensitization when the client makes which statement?

Accepted Answer

Answer reason: I will tell the nurse at the hospital that I had RhoGAM during pregnancy. An Rh-negative, unsensitized (Coombs-negative) pregnant client typically receives Rho(D) immune globulin (RhoGAM) around 28 weeks and may need an additional dose postpartum if the newborn is Rh-positive, as well as after any potential fetomaternal hemorrhage events. Informing the hospital team that she already received antenatal RhoGAM helps ensure appropriate timing and evaluation for postpartum prophylaxis. The other statements reflect misconceptions: RhoGAM is not given monthly, it does not prevent future pregnancies, and Rh-negative clients may still need prophylaxis in subsequent pregnancies.
Category reason: This item tests nursing education and management of Rh-negative pregnancy, including timing/communication about RhoGAM prophylaxis during pregnancy and after delivery, which is core Ante-Intra-Postpartum Care content.

Question 14

The priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy is to?

Accepted Answer

Answer reason: assess fetal heart rate (FHR) and maternal vital signs. In late-pregnancy bleeding (e.g., placenta previa or placental abruption), the immediate priority is to assess maternal hemodynamic stability and fetal well-being. Maternal vital signs identify potential hypovolemia/shock, while FHR assessment detects fetal distress from compromised uteroplacental perfusion. The other actions (pads for quantifying bleeding, labs, contraction monitoring) are important but come after the initial rapid maternal-fetal assessment to guide urgency and escalation of care.
Category reason: This is a maternity admission scenario requiring prioritization of immediate nursing assessment actions for a pregnant client with bleeding, which falls under antepartum/intrapartum nursing care rather than basic science knowledge.

Question 15

In which trimester does the fetal heartbeat usually become detectable by ultrasound?

Accepted Answer

Answer reason: First trimester Fetal cardiac activity can typically be detected by transvaginal ultrasound around 5.5–6 weeks’ gestation, which falls in the first trimester. Transabdominal ultrasound may detect it slightly later (often ~6–7+ weeks), but still within the first trimester. Therefore, the first trimester is the earliest and usual timeframe for ultrasound detection of fetal heartbeat.
Category reason: This question tests a routine prenatal milestone (timing of detecting fetal heartbeat by ultrasound) used in pregnancy assessment and counseling, which fits Ante-Intra-Postpartum Care under Growth and Development.

Question 16

True or False: Supine positioning is preferred for pregnant women in their third trimester.?

Accepted Answer

Answer reason: False In the third trimester, lying supine can cause aortocaval compression by the gravid uterus, reducing venous return and cardiac output and potentially decreasing uteroplacental perfusion. This can lead to maternal hypotension, dizziness, nausea, and fetal compromise. Left lateral (or with a wedge under the right hip to tilt) positioning is preferred to relieve vena cava compression and optimize maternal-fetal circulation.
Category reason: This item tests safe positioning recommendations during late pregnancy to prevent maternal hypotension and impaired uteroplacental blood flow, which is part of antepartum/intrapartum nursing care.

Question 17

Rho(D) immune globulin (RhoGAM) is prescribed for a woman after the delivery of a newborn infant, and the nurse provides information to the woman about the purpose of the medication. The nurse determines that the woman understands the purpose of the medication if the woman states that it will protect her next baby from which condition?

Accepted Answer

Answer reason: Being affected by Rh incompatibility. Rho(D) immune globulin prevents an Rh-negative mother from becoming sensitized to Rh-positive fetal red blood cells that may have entered her circulation during delivery. By preventing maternal anti-D antibody formation, it reduces the risk of hemolytic disease of the fetus/newborn in a subsequent Rh-positive pregnancy. It does not change the baby’s Rh type, prevent viral infections such as rubella, or address physiologic newborn jaundice unrelated to immune hemolysis.
Category reason: This question tests postpartum patient teaching about the purpose of Rh immune globulin to prevent complications in future pregnancies, which is an antepartum/intrapartum/postpartum nursing care concept.

Question 18

When is the first dose of T.T. injection given during pregnancy?

Accepted Answer

Answer reason: At 3rd month In routine antenatal immunization for tetanus prevention, the first dose of tetanus toxoid (or Td/Tdap depending on local protocol) is commonly initiated early in the second trimester/around the end of the first trimester, with the second dose given at least 4 weeks later. Starting around the third month allows time for maternal antibody production and transplacental transfer to protect the newborn against neonatal tetanus. Giving it in the first month is not standard scheduling in many antenatal programs, while giving it after the 9th month would be too late to reliably achieve protective antibody levels before delivery.
Category reason: This question tests recommended timing of immunization as part of routine prenatal (antenatal) care, which fits Ante-Intra-Postpartum Care under Health Promotion and Maintenance.

Question 19

The nurse in the postpartum unit notes that a new mother was given Methergine intramuscularly following delivery. What assessment finding indicates that the medication was effective?

Accepted Answer

Answer reason: Decreased uterine bleeding Methergine (methylergonovine) is a uterotonic given postpartum to increase uterine tone and promote sustained uterine contraction, which helps prevent or treat postpartum hemorrhage due to uterine atony. An effective response is reduced uterine blood loss as the contracted uterus compresses uterine blood vessels. Serous lochia reflects a normal time-based change in lochia rather than a direct indicator of uterotonic effectiveness. Blood pressure monitoring is important because hypertension can be an adverse effect, but normal pressure does not demonstrate therapeutic success; decreased contractions would indicate lack of desired effect.
Category reason: This item tests postpartum nursing assessment of a uterotonic medication’s therapeutic effect after delivery, which is part of antepartum/intrapartum/postpartum care decision-making.

Question 20

A pregnant client in her third trimester reports epigastric pain, headache, and visual disturbances. What should the nurse suspect?

Accepted Answer

Answer reason: Epigastric/RUQ pain, headache, and visual changes in the third trimester are classic severe-feature warning signs of hypertensive disorders of pregnancy due to endothelial dysfunction and possible hepatic involvement. These symptoms raise concern for progression toward severe preeclampsia/eclampsia and require prompt assessment of blood pressure, proteinuria, reflexes, and fetal status. Placenta previa typically presents with painless bright-red bleeding, preterm labor with regular contractions/cervical change, and hyperemesis gravidarum with severe early-pregnancy nausea/vomiting and dehydration.
Category reason: This is an obstetric nursing assessment question requiring recognition of a pregnancy complication and appropriate suspicion based on maternal symptoms, which fits antepartum care.

Question 21

A woman at 29 weeks with preterm premature rupture of membranes (PPROM) has no contractions. What is the best management?

Accepted Answer

Answer reason: At 29 weeks with PPROM and no labor, expectant inpatient management is preferred to balance prematurity risks against infection and fetal compromise. Admission allows close monitoring for chorioamnionitis, placental abruption, and fetal status, and enables timely intervention if complications occur. Antenatal corticosteroids are recommended to accelerate fetal lung maturation and reduce risks such as RDS and intraventricular hemorrhage. Immediate delivery (induction or cesarean) is not indicated without labor, infection, nonreassuring fetal status, or other obstetric indications, and outpatient management is unsafe due to rapid deterioration risk.
Category reason: This is an obstetric management question about how to care for a pregnant client with PPROM, focusing on appropriate inpatient monitoring and antenatal interventions, which fits Ante-Intra-Postpartum Care.

Question 22

A pregnant woman with history of cervical insufficiency has a cerclage placed at 14 weeks. What is the primary purpose of this procedure?

Accepted Answer

Answer reason: Cervical cerclage provides mechanical support to a weak or shortening cervix to reduce cervical dilation and membrane prolapse during the second trimester. This helps maintain the pregnancy and lowers the risk of pregnancy loss or premature birth in patients with cervical insufficiency. It does not treat cancer, change amniotic fluid volume, or specifically prevent uterine contractions; its goal is to prevent early opening of the cervix.
Category reason: This question tests a pregnancy intervention (cerclage) used to prevent obstetric complications in a client with cervical insufficiency, which falls under antepartum/intrapartum nursing care.

Question 23

A client at 32 weeks gestation is diagnosed with placenta previa. What should the nurse include in discharge teaching?

Accepted Answer

Answer reason: Placenta previa places the client at high risk for sudden, painless, potentially heavy antepartum hemorrhage, which can rapidly threaten maternal and fetal oxygenation. Prompt evaluation is needed for maternal vital signs, fetal monitoring, and readiness for blood products and possible urgent delivery. Teaching should emphasize immediate hospital evaluation with any bleeding and avoidance of activities that can provoke bleeding (e.g., intercourse, vaginal exams) rather than routine strict bed rest or planned induction.
Category reason: This item tests discharge teaching and safety actions for a pregnant client with placenta previa, which is an antepartum complication managed with nursing education and monitoring decisions in Ante-Intra-Postpartum Care.

Question 24

A patient with complete placenta previa is admitted at 37 weeks. Which of the following is contraindicated?

Accepted Answer

Answer reason: In complete placenta previa, the placenta covers the cervical os, so digital or speculum vaginal exams can disrupt placental tissue and provoke massive maternal hemorrhage. Management focuses on minimizing cervical manipulation while monitoring maternal-fetal status and preparing for delivery by cesarean at term or earlier if bleeding/instability occurs. Fetal monitoring, IV access/fluids, and cesarean preparation are appropriate supportive measures, but vaginal examination is avoided until placenta location is definitively excluded.
Category reason: This item tests an obstetric nursing safety decision in a pregnancy complication (placenta previa), specifically what assessment/intervention is contraindicated in intrapartum/antepartum care.

Question 25

A woman with Rh-negative blood delivers an Rh-positive baby. When should Rho(D) immune globulin be given?

Accepted Answer

Answer reason: B. Within 72 hours of delivery Rh immune globulin is administered postpartum to prevent maternal sensitization from fetal Rh-positive red blood cells that may have entered maternal circulation during delivery. Giving it within 72 hours maximizes effectiveness in preventing formation of maternal anti-D antibodies, which could harm future Rh-positive pregnancies (e.g., hemolytic disease of the newborn). A direct Coombs result does not determine whether prophylaxis is needed, and prophylaxis is not indicated if the infant is Rh-negative. Routine antenatal prophylaxis is typically given later in pregnancy (e.g., around 28 weeks), not at the first prenatal visit.
Category reason: This question tests peripartum nursing care and prevention of Rh isoimmunization following delivery, which is part of antepartum/intrapartum/postpartum management.

Question 26

Which finding in a 4-hours postpartum client is expected?

Accepted Answer

Answer reason: At about 4 hours postpartum, the uterine fundus is typically firm, midline, and located at or near the level of the umbilicus due to uterine contraction and involution. A temperature of 102°F suggests infection (e.g., endometritis) rather than normal early postpartum changes. Foul-smelling lochia is abnormal and concerning for infection. Lochia is expected to be rubra (bloody) in the first 1–3 days, so scant lochia serosa this early is not expected.
Category reason: This question tests expected normal maternal assessment findings and early postpartum physiologic changes, which fall under antepartum/intrapartum/postpartum nursing care.

Question 27

A woman reports passing a large clot at home on day 3 postpartum. She is not dizzy and lochia has slowed. What should the nurse advise?

Accepted Answer

Answer reason: e." Passing a single large clot around postpartum day 3 can occur as pooled blood is expelled, particularly when lochia is otherwise decreasing and there are no symptoms of hypovolemia. The key safety discriminator is ongoing heavy bleeding, recurrent large clots, worsening uterine atony signs, fever, or dizziness/syncope, which would require urgent evaluation. In this scenario the report suggests lochia is slowing and she is clinically stable, so reassurance with clear return precautions is the most appropriate advice.
Category reason: This item tests postpartum assessment and nursing advice regarding lochia and when to seek urgent care, which is part of routine ante-/intra-/postpartum nursing care.

Question 28

Which test is done at 28 weeks of pregnancy?

Accepted Answer

Answer reason: B. Glucose challenge test Gestational diabetes screening is typically performed at 24–28 weeks’ gestation in average-risk pregnancies, making this the appropriate timing. Group B streptococcus screening is usually done later, around 36–37 weeks. Nuchal translucency is a first-trimester screening (about 11–14 weeks), and chorionic villus sampling is a diagnostic test done in the first trimester (about 10–13 weeks).
Category reason: This question tests knowledge of the timing of standard prenatal screening during pregnancy, which falls under antepartum care in Health Promotion and Maintenance.

Question 29

A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions. The nurse determines that the client is experiencing Braxton Hicks contractions. Based on this finding, which nursing action is appropriate?

Accepted Answer

Answer reason: Braxton Hicks contractions are intermittent, irregular “practice” contractions that can occur throughout pregnancy and do not cause progressive cervical dilation like true labor. The appropriate nursing action is to provide reassurance and education, including when to seek care (e.g., contractions becoming regular, increasing in intensity, associated bleeding, rupture of membranes, or decreased fetal movement). Escalating to admission or ordering strict bed rest is not indicated based solely on typical Braxton Hicks findings, and routine provider notification is unnecessary if there are no signs of preterm labor or complications.
Category reason: This item tests prenatal nursing assessment and client teaching about normal physiologic changes in pregnancy (Braxton Hicks vs true labor), which fits Ante-Intra-Postpartum Care under Health Promotion and Maintenance.

Question 30

A 32 year old client, previously normotensive, has blood pressures 142/98 and 146/89 on two separate days this week. She is 28 weeks gestation. The nurse knows the client has developed?

Accepted Answer

Answer reason: New-onset hypertension after 20 weeks of gestation in a previously normotensive patient, documented on at least two occasions, meets criteria for this diagnosis when there is no information indicating proteinuria or end-organ dysfunction. Chronic hypertension would be present before pregnancy or before 20 weeks. HELLP requires evidence of hemolysis, elevated liver enzymes, and low platelets, which are not provided. Gestational diabetes is a glucose-intolerance diagnosis and does not explain the elevated blood pressures.
Category reason: This item tests recognition of a pregnancy-related hypertensive disorder based on gestational age and blood pressure readings, which is part of antepartum assessment and care planning.

Question 31

In shoulder dystocia, first maneuver to relieve impaction?

Accepted Answer

Answer reason: This is the recommended first-line intervention for shoulder dystocia because maternal hip hyperflexion increases the anteroposterior diameter of the pelvis and helps free the impacted anterior shoulder. It is rapid, low-risk, and can be performed immediately while maintaining continuous obstetric support and fetal monitoring. If unsuccessful, additional maneuvers such as suprapubic pressure and internal rotational techniques (e.g., Woods screw) are attempted; surgical options like symphysiotomy or cesarean are not first maneuvers once the head has delivered.
Category reason: This question tests immediate intrapartum management of an obstetric emergency (shoulder dystocia) and the correct sequence of maneuvers during childbirth, which fits Ante-Intra-Postpartum Care.

Question 32

Which finding indicates a Category III fetal heart rate (FHR) tracing, requiring immediate intervention?

Accepted Answer

Answer reason: B) Recurrent late decelerations with absent variability This pattern meets Category III criteria because absent baseline variability combined with recurrent late decelerations indicates inadequate fetal oxygenation and possible acidemia. Late decelerations reflect uteroplacental insufficiency, and when variability is absent, fetal compensatory mechanisms are failing. Category III requires prompt intrauterine resuscitation (e.g., maternal repositioning, IV fluid bolus, stopping oxytocin, treating hypotension, oxygen per facility policy) and preparation for expedited delivery if unresolved.
Category reason: This question tests interpretation of intrapartum fetal heart rate patterns and the required nursing response, which is a core component of antepartum/intrapartum/postpartum care.

Question 33

A postpartum client reports painful, swollen breasts. What nursing intervention is most appropriate?

Accepted Answer

Answer reason: Warmth applied just before feeding promotes milk let-down and improves milk flow, helping relieve engorgement and associated pain. Continuing frequent breastfeeding is recommended to empty the breasts and prevent blocked ducts and mastitis. Decreasing feeds or substituting formula can worsen engorgement by reducing effective milk removal. Forceful massage can cause tissue trauma and increase inflammation rather than safely improving drainage.
Category reason: This item tests appropriate nursing management of a common postpartum breastfeeding complication (engorgement), which falls under antepartum/intrapartum/postpartum care within Health Promotion and Maintenance.

Question 34

A 30-week pregnant woman with gestational diabetes shows polyhydramnios on ultrasound. What fetal condition should the nurse monitor for?

Accepted Answer

Answer reason: Maternal hyperglycemia leads to fetal hyperinsulinemia, which promotes excessive fetal growth. Polyhydramnios is commonly associated with poorly controlled diabetes in pregnancy due to fetal osmotic diuresis from hyperglycemia. Therefore the fetus is at higher risk for excessive size and related birth complications compared with the other listed conditions.
Category reason: This question focuses on monitoring for a common fetal complication of gestational diabetes during pregnancy, which is part of antepartum care and risk surveillance.

Question 35

A client at 5 cm dilatation receiving IV penicillin for GBS positive status asks why she needs it. Best response?

Accepted Answer

Answer reason: B. "It reduces newborn infection risk during birth." Intrapartum IV penicillin is given to clients who are GBS-positive to decrease vertical transmission of Group B Streptococcus to the newborn during labor and delivery. This reduces the risk of early-onset neonatal sepsis, pneumonia, and meningitis. The medication does not enhance uterine contractions, accelerate labor, or prevent hypertensive disorders of pregnancy.
Category reason: This is a labor-and-delivery patient education question about intrapartum antibiotic prophylaxis for GBS, which is part of antepartum/intrapartum nursing care.

Question 36

A patient is in the second stage of labor. During this stage, how frequently should the nurse in charge assess her uterine contractions?

Accepted Answer

Answer reason: In the second stage of labor, contractions are typically frequent and intense, and close monitoring helps detect labor dystocia and signs of maternal/fetal compromise early. Standard intrapartum nursing assessment increases in frequency as labor progresses, with the second stage requiring very frequent evaluation of uterine activity. Frequent assessment supports timely interventions (e.g., position changes, coaching, notifying the provider) if contractions become inadequate or excessive. The longer intervals listed are more consistent with earlier labor stages and risk delayed recognition of complications.
Category reason: This question tests intrapartum nursing monitoring frequency during the second stage of labor, which is a patient-care judgment within antepartum/intrapartum/postpartum nursing.

Question 37

A nurse is caring for a client in active labor and observes early decelerations on the fetal heart rate (FHR) tracing. Which action should the nurse take next?

Accepted Answer

Answer reason: D. Continue to monitor the client and the FHR. Early decelerations are typically a benign, expected pattern in labor caused by fetal head compression and are usually associated with cervical dilation and contractions. They generally do not indicate fetal hypoxia or uteroplacental insufficiency, so immediate intrauterine resuscitation measures are not required. The appropriate nursing action is ongoing assessment of the tracing and labor progress while maintaining routine supportive care. Escalation actions like fluid bolus or amnioinfusion are reserved for patterns suggestive of compromised perfusion/oxygenation (e.g., variable or late decelerations) or other nonreassuring findings.
Category reason: This item tests nursing management of intrapartum fetal monitoring and the appropriate response to a specific FHR pattern during labor, which is part of antepartum/intrapartum care decision-making.

Question 38

When should pelvic examination be done postnatally?

Accepted Answer

Answer reason: Routine postpartum assessment includes monitoring vital signs, uterine involution, lochia, perineal healing, and breastfeeding, and does not require an internal pelvic exam in every patient. A pelvic examination is performed when there is a clinical indication such as suspected retained products, postpartum hemorrhage, infection/endometritis, significant perineal trauma complications, or persistent/worsening symptoms. Unnecessary pelvic exams can increase discomfort and introduce infection risk, so they should be reserved for situations where findings will change management.
Category reason: This question asks about appropriate timing/indications for a postpartum (postnatal) pelvic examination, which is part of routine maternal care and assessment during the postpartum period.

Question 39

The pregnant client is 7 centimeters, 100% effaced, and at a +1 station. The fetus is in a face presentation. The nurse concludes that teaching has been effective when the client’s husband states?

Accepted Answer

Answer reason: t." In a face presentation, the fetal head is hyperextended so the face (mentum) becomes the presenting part felt on exam and ultimately leads through the birth canal. This differs from vertex/occiput presentations where the back of the head leads, and from breech where the buttocks present first. “Facing one hip” describes a transverse or shoulder-related orientation rather than a face presentation.
Category reason: This item tests understanding of fetal presentations during labor and evaluation of patient/family teaching in the intrapartum period, which aligns with Ante-Intra-Postpartum Care.

Question 40

What lab test is commonly advised during postnatal follow-up?

Accepted Answer

Answer reason: Postnatal follow-up commonly includes screening for postpartum anemia due to blood loss during delivery and increased iron demands during pregnancy. Checking hemoglobin helps identify clinically significant anemia that can contribute to fatigue, poor recovery, and impaired lactation/parenting capacity. The other tests are not routine postpartum surveillance labs unless there is a specific clinical indication (e.g., hypertensive disorders, hepatic disease, or pancreatitis).
Category reason: This question tests routine postnatal (postpartum) follow-up care and recommended assessment after delivery, which aligns with Ante-Intra-Postpartum Care in Health Promotion and Maintenance.

Question 41

A nurse is assessing a woman who is currently pregnant for the third time. She has a history of one miscarriage at 10 weeks gestation and one full-term delivery of a healthy infant. Which of the following accurately describes her gravida and para status?

Accepted Answer

Answer reason: B. Multigravida, Primipara Gravida counts total pregnancies including the current one, so being pregnant for the third time makes her a multigravida (G3). Para counts births at viability (about ≥20 weeks), and she has had one full-term delivery, so she is primipara (P1). The miscarriage at 10 weeks is included in gravida but not counted in para because it occurred before viability. Therefore the combined status is multigravida, primipara.
Category reason: This question tests obstetric history terminology (gravida/para) used in prenatal assessment and documentation, which is part of antepartum care in maternity nursing.

Question 42

Q.1428: What is Ballottement used to assess?

Accepted Answer

Answer reason: Ballottement is a physical examination technique in pregnancy where the examiner taps the presenting part through the cervix or abdominal wall and feels it rebound, indicating the fetus is floating rather than fixed in the pelvis. This finding helps infer that the presenting part has not descended and become firmly engaged. If the presenting part is engaged, it will feel fixed and will not “bounce” back. Thus, it is used to assess engagement/descent of the presenting part.
Category reason: This question tests an antenatal/intrapartum assessment maneuver used during pregnancy to evaluate fetal descent/engagement, which is part of routine ante-intra-postpartum nursing care rather than foundational biomedical science.

Question 43

Which condition is A contraindications For breastfeeding?

Accepted Answer

Answer reason: Untreated/active tuberculosis in the mother is a contraindication to direct breastfeeding because of the risk of airborne transmission to the infant during close contact. Breast milk itself is not the primary transmission route, but the mother-infant proximity can expose the newborn before the mother is no longer infectious (e.g., after adequate therapy). In contrast, maternal hypertension and anemia generally do not prohibit breastfeeding; they typically require management and monitoring rather than cessation of breastfeeding.
Category reason: This item tests breastfeeding eligibility/safety in the postpartum period, which is part of maternal-newborn nursing care and therefore fits Ante-Intra-Postpartum Care.

Question 44

During Which stage of labour placenta is delivered?

Accepted Answer

Answer reason: The stages of labor are classically: first stage (onset of true labor to full cervical dilation), second stage (full dilation to birth of the baby), and third stage (birth of the baby to delivery of the placenta). Placental separation and expulsion occur after the neonate is delivered, making it the defining event of the third stage. The fourth stage refers to the immediate postpartum recovery period, focused on maternal stabilization and monitoring for hemorrhage.
Category reason: This question tests knowledge of intrapartum/partum milestones (stages of labor and when placental delivery occurs), which is part of Ante-Intra-Postpartum Care.

Question 45

A mother should avoid breastfeeding if she is taking?

Accepted Answer

Answer reason: Cytotoxic agents can pass into breast milk and may cause serious toxicity in the infant (e.g., bone marrow suppression, immunosuppression, gastrointestinal injury, and impaired growth). For this reason, breastfeeding is generally contraindicated during maternal chemotherapy, and mothers are advised to stop breastfeeding (and often discard milk) until the drug is cleared based on the specific regimen. In contrast, iron and calcium supplements are compatible with breastfeeding, and paracetamol is generally considered safe at usual therapeutic doses.
Category reason: This question focuses on maternal medication safety during breastfeeding and the nursing guidance on whether to continue lactation in the postpartum period, fitting Ante-Intra-Postpartum Care.

Question 46

The nurse is caring for a client in labor. The fetal monitor shows late decelerations. What is the priority nursing action?

Accepted Answer

Answer reason: Late decelerations are associated with uteroplacental insufficiency and reduced fetal oxygenation during contractions. Maternal lateral positioning (left side preferred) improves uterine perfusion by reducing aortocaval compression and can quickly improve fetal oxygen delivery. Increasing oxytocin can worsen uterine tachysystole and fetal hypoxia, so it is not appropriate as a first action. The provider should be notified if late decelerations persist after initial intrauterine resuscitation measures.
Category reason: This item tests an immediate nursing intervention during labor based on fetal heart rate monitoring changes, which is an intrapartum care priority within ante-, intra-, and postpartum nursing care.

Question 47

Active management of third stage of labour (AMTSL) includes all except:

Accepted Answer

Answer reason: AMTSL is designed to prevent postpartum hemorrhage by promoting effective uterine contraction and facilitating placental delivery. Standard components include administration of a uterotonic (e.g., oxytocin) soon after birth, controlled cord traction with uterine support, and uterine/fundal massage after placental expulsion to maintain tone. Routine early cord clamping is not a core component in contemporary guidance; delayed cord clamping is generally preferred for neonatal benefit unless contraindicated.
Category reason: This question tests intrapartum/postpartum nursing management of the third stage of labor, including interventions used to prevent postpartum hemorrhage, which aligns with ante-, intra-, and postpartum care.

Question 48

To prevent maternal antibody formation, RhoGAM should be administered in certain situations. Which of the following situations would RhoGAM be administered to a mother who is Rh-negative?

Accepted Answer

Answer reason: D. Following the birth of an Rh-positive newborn Rho(D) immune globulin is given to an Rh-negative mother when there is risk of fetomaternal hemorrhage involving Rh-positive fetal red blood cells, which could sensitize her immune system. Administering it postpartum after delivery of an Rh-positive infant prevents formation of anti-D antibodies and reduces risk of hemolytic disease in future pregnancies. It is not indicated after delivery of an Rh-negative newborn because there is no Rh(D) antigen exposure to trigger sensitization. ABO incompatibility is a separate issue and is not the indication for Rho(D) immune globulin.
Category reason: This is primarily about an obstetric preventive intervention (when to administer Rho(D) immune globulin) in the postpartum period, which aligns with Ante-Intra-Postpartum Care.

Question 49

A patient in the first stage of labor is complaining of back pain and has a prolonged labor. The nurse identifies that the fetus is in the occiput posterior (OP) position. Which of the following positions is the most important for the nurse to encourage the patient to assume to help promote rotation of the fetus?

Accepted Answer

Answer reason: C. Hands and knees position This position uses gravity and pelvic mechanics to reduce pressure on the maternal sacrum and encourages anterior rotation of the fetal occiput, which can decrease back labor and help labor progress. It can also improve fetal head flexion and alignment with the maternal pelvis. In contrast, supine and lithotomy positions may worsen aortocaval compression and do not facilitate rotation, and Trendelenburg is not a standard or safe technique to promote fetal rotation in labor.
Category reason: This item tests an intrapartum nursing intervention (maternal positioning) to improve fetal position and labor progress, which fits Ante-Intra-Postpartum Care.

Question 50

After the birth of baby by vaginal delivery, breastfeeding should be initiated within?

Accepted Answer

Answer reason: Early initiation of breastfeeding is recommended as soon as possible after birth, ideally within the first hour, to promote skin-to-skin contact, support neonatal thermoregulation and glucose stability, and enhance maternal-infant bonding. The first hour also aligns with newborn alertness and feeding readiness, which improves latch success and milk transfer. Early suckling stimulates oxytocin release, helping uterine involution and reducing postpartum bleeding risk. Delaying several hours can increase feeding difficulties and reduce the benefits of early colostrum intake.
Category reason: This question tests immediate postpartum newborn feeding practice and timing of breastfeeding initiation, which is part of perinatal nursing care under Ante-Intra-Postpartum Care.

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