🤰FINAL🤰 Flashcards
1
Q
A nurse is educating a group of nursing students about maternal mortality in the United States. Which of the following statements by a student indicates the need for further teaching?
a. “Maternal mortality is defined as the number of deaths during pregnancy or within 42 days of termination per 100,000 live births.”
b. “African American women have the lowest risk of maternal mortality.”
c. “The leading causes of maternal mortality include postpartum hemorrhage and cardiovascular disease.”
d. “Most maternal deaths are preventable.”
A
Answer: b. “African American women have the lowest risk of maternal mortality.”
Rationale: African American women are at the highest risk for maternal mortality due to disparities in healthcare access and systemic factors.
2
Q
The nurse is assessing infant mortality rates in a local community. Which of the following would be the best indicator of maternal and newborn health quality in that area?
a. Neonatal mortality rate
b. Maternal morbidity rate
c. Total number of live births
d. The number of premature births
A
Answer: a. Neonatal mortality rate
Rationale: The neonatal mortality rate (deaths in the first 28 days per 1,000 live births) is a key indicator of maternal and newborn healthcare quality.
3
Q
A nurse is teaching a prenatal class about factors that impact maternal health. Which statement indicates that the participant understands the teaching?
a. “Genetics has no impact on maternal health outcomes.”
b. “Social determinants of health, such as access to healthcare, influence pregnancy outcomes.”
c. “The media does not affect maternal health decisions.”
d. “Women of color experience the same maternal health outcomes as white women.”
A
Answer: b. “Social determinants of health, such as access to healthcare, influence pregnancy outcomes.”
Rationale: Social determinants of health, including healthcare access, socioeconomic status, and systemic disparities, greatly influence maternal health outcomes.
4
Q
A patient at 12 weeks gestation asks why maternal health disparities exist. The nurse explains that factors contributing to these disparities include:
a. Genetic predisposition to complications
b. Variability in personal diet choices
c. Limited access to quality healthcare and socioeconomic disparities
d. Differences in prenatal vitamin intake
A
Answer: c. Limited access to quality healthcare and socioeconomic disparities
Rationale: Social determinants of health, including healthcare access, systemic bias, and economic instability, significantly impact maternal outcomes.
5
Q
The nurse is obtaining informed consent from a patient undergoing a cesarean section. Which statement by the patient indicates understanding?
a. “I signed the form because my nurse told me to, but I don’t really understand it.”
b. “My doctor explained the risks, benefits, and alternatives, and I have the right to change my mind.”
c. “Only my husband needs to understand the procedure.”
d. “If I refuse the surgery, the doctor can perform it anyway in an emergency.”
A
Answer: b. “My doctor explained the risks, benefits, and alternatives, and I have the right to change my mind.”
Rationale: Informed consent requires understanding the risks, benefits, and alternatives, and the patient has the right to withdraw consent at any time.
6
Q
A nurse is acting as a witness for a patient’s informed consent. Which of the following statements by the nurse is correct?
a. “I am responsible for ensuring the patient fully understands the procedure.”
b. “I can answer all medical questions about the procedure for the patient.”
c. “I am verifying that the patient signed the consent voluntarily.”
d. “Once the consent is signed, the patient cannot refuse the procedure.”
A
Answer: c. “I am verifying that the patient signed the consent voluntarily.”
Rationale: The nurse’s role in informed consent is to ensure the form is signed voluntarily and to witness the signature.
7
Q
The nurse is teaching a group of adolescents about the menstrual cycle. Which statement indicates an understanding of ovulation?
a. “Ovulation occurs on the first day of my period.”
b. “My body releases progesterone to stimulate ovulation.”
c. “Ovulation occurs around day 14 of a 28-day cycle and is triggered by an LH surge.”
d. “Estrogen levels are lowest during ovulation.”
A
Answer: c. “Ovulation occurs around day 14 of a 28-day cycle and is triggered by an LH surge.”
Rationale: The luteinizing hormone (LH) surge triggers ovulation around day 14 in a typical 28-day cycle.
8
Q
A nurse is discussing hormone fluctuations during the menstrual cycle. Which hormone primarily supports the luteal phase and prepares the body for pregnancy?
a. Estrogen
b. Luteinizing hormone (LH)
c. Progesterone
d. Follicle-stimulating hormone (FSH)
A
Answer: c. Progesterone
Rationale: Progesterone is secreted by the corpus luteum after ovulation to maintain the endometrium for potential implantation.
9
Q
A patient taking combined oral contraceptives (COCs) calls the clinic reporting severe leg pain. What should the nurse suspect?
a. Normal side effect of estrogen
b. Deep vein thrombosis (DVT)
c. Appendicitis
d. Gastrointestinal cramping
A
Answer: b. Deep vein thrombosis (DVT)
Rationale: Severe leg pain may indicate a DVT, a serious complication associated with estrogen-containing contraceptives.
10
Q
A nurse is teaching a patient about the side effects of oral contraceptives. The patient should seek immediate medical attention if which of the following occurs?
a. Mild nausea
b. Spotting between periods
c. Sudden chest pain and shortness of breath
d. Mild breast tenderness
A
Answer: c. Sudden chest pain and shortness of breath
Rationale: Chest pain and shortness of breath may indicate a pulmonary embolism, a serious side effect of COCs.
11
Q
A patient at 12 weeks gestation asks about the purpose of an ultrasound. Which response by the nurse is correct?
a. “It can only confirm the baby’s gender.”
b. “It is used to check for structural abnormalities and assess fetal development.”
c. “It replaces all genetic screening tests.”
d. “It should only be done after 20 weeks.”
A
Answer: b. “It is used to check for structural abnormalities and assess fetal development.”
Rationale: Ultrasound is used in early pregnancy to evaluate fetal development and detect structural abnormalities.
12
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13
Q
A nurse is reviewing maternal morbidity data. Which of the following conditions is the leading cause of pregnancy-related deaths in the U.S.?
a. Hemorrhage
b. Preeclampsia and eclampsia
c. Infection
d. Cardiovascular disease
A
Answer: d. Cardiovascular disease
Rationale: Cardiovascular conditions are the leading cause of maternal mortality in the U.S., followed by hemorrhage, preeclampsia, and infection.
14
Q
A nurse is analyzing fetal mortality rates in a community. Which intervention is most effective in reducing fetal mortality?
a. Routine prenatal genetic testing
b. Comprehensive prenatal care
c. Early gender determination
d. Encouraging bed rest in all pregnancies
A
Answer: b. Comprehensive prenatal care
Rationale: Access to prenatal care significantly reduces fetal mortality by addressing risk factors like preeclampsia, infections, and preterm birth.
15
Q
A nurse is discussing social determinants of health with a group of nursing students. Which factor most contributes to disparities in maternal healthcare?
a. Lack of access to nutritious food
b. Personal hygiene habits
c. Number of prenatal vitamins taken
d. Use of complementary therapies
A
Answer: a. Lack of access to nutritious food
Rationale: Access to nutritious food directly impacts pregnancy outcomes and is a key social determinant of health.
16
Q
Which factor places women of color at a higher risk for pregnancy-related complications?
a. Genetic predisposition
b. Higher rate of cesarean sections
c. Delayed access to prenatal care
d. Increased use of home births
A
Answer: c. Delayed access to prenatal care
Rationale: Many systemic and structural issues contribute to delayed or inadequate prenatal care, increasing risks for complications.
17
Q
A nurse is explaining informed consent to a pregnant patient. Which statement best describes the nurse’s role?
a. “I will provide a detailed explanation of the procedure.”
b. “I will ensure you understand the risks, benefits, and alternatives before you sign.”
c. “I am only here to witness your signature on the form.”
d. “Once you sign, the procedure must be done.”
A
Answer: b. “I will ensure you understand the risks, benefits, and alternatives before you sign.”
Rationale: The nurse ensures the patient fully understands the procedure before signing. The provider explains the procedure.
18
Q
In which situation would a minor be legally allowed to provide informed consent for a medical procedure without parental approval?
a. A 17-year-old seeking prenatal care
b. A 16-year-old needing surgery for a broken leg
c. A 14-year-old requesting antibiotics for a sinus infection
d. A 15-year-old wanting a flu vaccine
A
Answer: a. A 17-year-old seeking prenatal care
Rationale: Many states allow minors to consent to pregnancy-related care without parental involvement.
19
Q
During the menstrual cycle, which hormone is responsible for triggering ovulation?
a. Progesterone
b. Estrogen
c. Luteinizing hormone (LH)
d. Follicle-stimulating hormone (FSH)
A
Answer: c. Luteinizing hormone (LH)
Rationale: The LH surge causes ovulation around day 14 of a 28-day cycle.
20
Q
A patient asks about the corpus luteum’s role in the menstrual cycle. The nurse correctly responds:
a. “It releases FSH to prepare the next cycle.”
b. “It releases progesterone to maintain the uterine lining for implantation.”
c. “It triggers ovulation by releasing LH.”
d. “It stimulates the pituitary gland to release estrogen.”
A
Answer: b. “It releases progesterone to maintain the uterine lining for implantation.”
Rationale: The corpus luteum releases progesterone, which supports implantation.
21
Q
A patient with endometriosis asks why she has pain during her menstrual cycle. The nurse explains:
a. “The pain occurs because of abnormal estrogen levels.”
b. “Endometrial-like tissue grows outside the uterus, causing inflammation and scarring.”
c. “The pain is due to uterine muscle contractions from progesterone withdrawal.”
d. “Endometriosis prevents ovulation, which leads to cramping.”
A
Answer: b. “Endometrial-like tissue grows outside the uterus, causing inflammation and scarring.”
Rationale: Endometriosis causes ectopic endometrial growth, leading to inflammation and pain.
22
Q
The definitive method for diagnosing endometriosis is:
a. Transvaginal ultrasound
b. Serum hormone levels
c. Laparoscopy
d. Pelvic exam
A
Answer: c. Laparoscopy
Rationale: Laparoscopy is the gold standard for diagnosing endometriosis.
23
Q
A nurse is teaching a patient about combined oral contraceptives (COCs). Which statement indicates understanding?
a. “COCs protect against sexually transmitted infections (STIs).”
b. “I can stop taking my pills anytime without any side effects.”
c. “If I miss three pills in a row, I need to use backup contraception.”
d. “COCs will permanently affect my ability to get pregnant.”
A
Answer: c. “If I miss three pills in a row, I need to use backup contraception.”
Rationale: Missing multiple COCs increases the risk of pregnancy, requiring backup contraception.
24
Q
Which patient should not be prescribed a COC?
a. A 32-year-old smoker
b. A 21-year-old with mild acne
c. A 27-year-old with irregular cycles
d. A 19-year-old who recently had a miscarriage
A
Answer: a. A 32-year-old smoker
Rationale: COCs increase the risk of blood clots, especially in smokers over 35.
25
A first-trimester ultrasound is primarily used to assess:
a. Placenta previa
b. Structural abnormalities
c. Fetal growth and heartbeat
d. Amniotic fluid levels
Answer: c. Fetal growth and heartbeat
Rationale: Early ultrasounds confirm pregnancy and assess fetal growth.
26
Which screening test is used for neural tube defects like spina bifida?
a. Amniocentesis
b. Quad screen (MSAFP)
c. Cell-free DNA testing
d. CVS (Chorionic Villus Sampling)
Answer: b. Quad screen (MSAFP)
Rationale: Maternal Serum Alpha-Fetoprotein (MSAFP) detects neural tube defects in the second trimester.
27
Which patient is at highest risk for developing gestational hypertension?
a. A 20-year-old primigravida with no medical history
b. A 28-year-old with a BMI of 22
c. A 35-year-old with a history of chronic hypertension
d. A 40-year-old pregnant with twins
Answer: d. A 40-year-old pregnant with twins
Rationale: Risk factors for gestational hypertension include advanced maternal age, multiple gestation, obesity, and preexisting hypertension.
27
A patient at 32 weeks gestation is diagnosed with gestational hypertension. Which finding differentiates this condition from preeclampsia?
a. Proteinuria is absent
b. Blood pressure is greater than 160/110 mmHg
c. The patient experiences blurred vision and headaches
d. The condition does not resolve postpartum
Answer: a. Proteinuria is absent
Rationale: Gestational hypertension is diagnosed when BP is ≥140/90 mmHg after 20 weeks, but without proteinuria or organ dysfunction.
28
A patient at 14 weeks gestation has blood pressure readings of 148/94 mmHg. What is the best diagnosis?
a. Preeclampsia
b. Chronic hypertension
c. Gestational hypertension
d. Eclampsia
Answer: b. Chronic hypertension
Rationale: Chronic hypertension is diagnosed when BP is ≥140/90 mmHg before pregnancy or before 20 weeks gestation.
29
Which medication is contraindicated for a pregnant patient with chronic hypertension?
a. Labetalol
b. Methyldopa
c. ACE inhibitors
d. Nifedipine
Answer: c. ACE inhibitors
Rationale: ACE inhibitors (e.g., lisinopril) are teratogenic and can cause fetal renal damage.
30
A nurse is caring for a preeclamptic patient. Which symptom requires immediate intervention?
a. Swelling in hands and feet
b. BP of 140/90 mmHg
c. Severe epigastric pain and headache
d. Weight gain of 2 lbs in a week
Answer: c. Severe epigastric pain and headache
Rationale: Severe epigastric pain, headache, and visual disturbances may indicate impending eclampsia or liver involvement (HELLP syndrome).
31
Which lab finding confirms superimposed preeclampsia in a patient with chronic hypertension?
a. Elevated liver enzymes
b. BP remains unchanged
c. No protein in the urine
d. Sodium level of 135 mEq/L
Answer: a. Elevated liver enzymes
Rationale: Superimposed preeclampsia occurs when a patient with chronic hypertension develops proteinuria or organ dysfunction.
32
A patient with HELLP syndrome is at risk for which complication?
a. Placenta previa
b. Disseminated intravascular coagulation (DIC)
c. Gestational diabetes
d. Polyhydramnios
Answer: b. Disseminated intravascular coagulation (DIC)
Rationale: HELLP syndrome involves hemolysis, elevated liver enzymes, and low platelets, increasing the risk for DIC.
33
Which lab result is expected in a patient with HELLP syndrome?
a. Increased hemoglobin
b. Increased platelet count
c. Increased liver enzymes
d. Decreased bilirubin
Answer: c. Increased liver enzymes
Rationale: Liver involvement causes increased AST/ALT and low platelets (<100,000).
34
A nurse is administering magnesium sulfate for preeclampsia. What is the primary goal of this treatment?
a. Lower maternal blood pressure
b. Reduce fetal heart rate
c. Prevent seizures
d. Stop labor contractions
Answer: c. Prevent seizures
Rationale: Magnesium sulfate is a CNS depressant that prevents eclampsia-related seizures.
35
What is a priority assessment during magnesium sulfate therapy?
a. Deep tendon reflexes (DTRs)
b. Blood glucose levels
c. Urine glucose
d. Fundal height
Answer: a. Deep tendon reflexes (DTRs)
Rationale: Diminished or absent DTRs are an early sign of magnesium toxicity.
36
Which sign indicates magnesium toxicity?
a. Hyperreflexia
b. Respiratory rate of 10 breaths/min
c. Increased urine output
d. Hypertension
Answer: b. Respiratory rate of 10 breaths/min
Rationale: Respiratory depression (<12 breaths/min) is a late sign of magnesium toxicity.
37
What is the antidote for magnesium toxicity?
a. Calcium chloride
b. Calcium gluconate
c. Sodium bicarbonate
d. Potassium chloride
Answer: b. Calcium gluconate
Rationale: Calcium gluconate (1g IV over 3 minutes) reverses magnesium toxicity.
38
A patient at 10 weeks gestation presents with mild cramping, vaginal bleeding, and a closed cervix. What type of spontaneous abortion is this?
a. Missed abortion
b. Threatened abortion
c. Inevitable abortion
d. Complete abortion
Answer: b. Threatened abortion
Rationale: A threatened abortion occurs when vaginal bleeding and cramping happen without cervical dilation.
39
Which spontaneous abortion requires immediate dilation and curettage (D&C)?
a. Complete abortion
b. Missed abortion
c. Threatened abortion
d. Incomplete abortion
Answer: d. Incomplete abortion
Rationale: Incomplete abortion occurs when some fetal tissue remains in the uterus, requiring D&C to prevent infection.
40
A patient with right lower quadrant pain, light spotting, and a positive pregnancy test is suspected of having an ectopic pregnancy. What is the priority intervention?
a. Monitor hCG levels
b. Administer methotrexate
c. Prepare for surgery
d. Start IV fluids
Answer: c. Prepare for surgery
Rationale: Ectopic pregnancy can cause rupture and hemorrhage, requiring emergency surgery if rupture occurs.
41
Which patient with an ectopic pregnancy is a candidate for methotrexate instead of surgery?
a. A patient with a ruptured fallopian tube
b. A patient with severe hypotension
c. A patient with an hCG level <5,000 and no fetal cardiac activity
d. A patient with severe abdominal pain and tachycardia
Answer: c. A patient with an hCG level <5,000 and no fetal cardiac activity
Rationale: Methotrexate is used for unruptured ectopic pregnancies with low hCG levels and no cardiac activity.
42
A patient at 18 weeks gestation presents with painless cervical dilation and bulging membranes. Which intervention is most appropriate?
a. Administer magnesium sulfate
b. Prepare for cerclage placement
c. Initiate oxytocin infusion
d. Encourage bedrest only
Answer: b. Prepare for cerclage placement
Rationale: Cervical cerclage is placed to reinforce the cervix and prevent preterm birth.
43
What assessment finding suggests cervical insufficiency?
a. Closed cervix with contractions
b. Cervical length <25 mm on ultrasound
c. Placental abruption
d. Increased amniotic fluid levels
Answer: b. Cervical length <25 mm on ultrasound
Rationale: Shortened cervix (<25 mm) increases the risk of preterm birth.
44
A pregnant patient presents with sudden dark red vaginal bleeding, severe abdominal pain, and a firm uterus. What is the most likely diagnosis?
a. Placenta previa
b. Placental abruption
c. Uterine rupture
d. Preterm labor
Answer: b. Placental abruption
Rationale: Placental abruption involves painful, dark red bleeding, a rigid uterus, and potential fetal distress.
45
Which risk factor is most strongly associated with placental abruption?
a. Obesity
b. Cocaine use
c. History of gestational diabetes
d. Advanced maternal age
Answer: b. Cocaine use
Rationale: Cocaine use causes vasoconstriction, increasing the risk of placental abruption.
46
A nurse is caring for a patient with placenta previa at 34 weeks gestation. Which intervention is contraindicated?
a. Administering corticosteroids
b. Monitoring fetal heart rate
c. Performing a digital vaginal exam
d. Scheduling a cesarean section
Answer: c. Performing a digital vaginal exam
Rationale: Vaginal exams are contraindicated in placenta previa due to the risk of severe hemorrhage.
47
A patient with marginal placenta previa asks if she can have a vaginal delivery. The nurse should respond:
a. "Yes, as long as the placenta moves away from the cervix before labor."
b. "No, all placenta previas require cesarean delivery."
c. "It depends on whether you have contractions."
d. "You will need an immediate induction of labor."
Answer: a. "Yes, as long as the placenta moves away from the cervix before labor."
Rationale: Marginal placenta previa may resolve before delivery, allowing for a trial of labor.
48
A patient with hyperemesis gravidarum is at risk for which complication?
a. Hypokalemia
b. Hyperglycemia
c. Hypertension
d. Polyhydramnios
Answer: a. Hypokalemia
Rationale: Severe vomiting leads to electrolyte imbalances, including hypokalemia and metabolic alkalosis.
49
Which medication is first-line treatment for hyperemesis gravidarum?
a. Labetalol
b. Promethazine (Phenergan)
c. Insulin
d. Misoprostol
Answer: b. Promethazine (Phenergan)
Rationale: Promethazine is an antiemetic commonly used for hyperemesis gravidarum.
50
A 28-week pregnant patient has a 1-hour glucose tolerance test result of 160 mg/dL. What is the next step?
a. Diagnose gestational diabetes
b. Perform a 3-hour glucose tolerance test
c. Start insulin therapy
d. Encourage increased carbohydrate intake
Answer: b. Perform a 3-hour glucose tolerance test
Rationale: A 1-hour glucose test >140 mg/dL requires a 3-hour glucose test for confirmation.
51
What is the preferred first-line treatment for gestational diabetes?
a. Metformin
b. Diet and exercise
c. Insulin
d. Oral contraceptives
Answer: b. Diet and exercise
Rationale: Lifestyle modifications are the first-line treatment for gestational diabetes.
52
A 32-week pregnant patient presents with regular contractions and a closed cervix. Which test can predict the likelihood of preterm birth?
a. Amniocentesis
b. Fetal fibronectin (fFN) test
c. Non-stress test (NST)
d. Biophysical profile
Answer: b. Fetal fibronectin (fFN) test
Rationale: A negative fFN test indicates a low risk of preterm birth within 1-2 weeks.
53
Which medication is used to delay preterm labor?
a. Oxytocin
b. Magnesium sulfate
c. Insulin
d. Heparin
Answer: b. Magnesium sulfate
Rationale: Magnesium sulfate is a tocolytic used to delay labor and protect fetal neurodevelopment.
54
A 10-week pregnant patient presents with light vaginal bleeding, mild cramping, and a closed cervix. What is the most appropriate nursing intervention?
a. Prepare the patient for an emergency D&C
b. Advise bed rest and pelvic rest
c. Administer oxytocin to promote contractions
d. Reassure the patient that bleeding is normal
Answer: b. Advise bed rest and pelvic rest
Rationale: A threatened abortion is managed with pelvic rest and monitoring for worsening symptoms.
55
A 12-week pregnant patient presents with moderate vaginal bleeding, cramping, and cervical dilation. Which finding confirms an inevitable abortion?
a. Fetal heart tones present
b. Cervix remains closed
c. Cervix is dilated with no passage of tissue
d. Ultrasound confirms an intact pregnancy
Answer: c. Cervix is dilated with no passage of tissue
Rationale: In an inevitable abortion, the cervix is open and pregnancy loss cannot be prevented.
56
A patient at 14 weeks gestation presents with heavy vaginal bleeding, cramping, and passage of some fetal tissue. The cervix is open. What is the priority nursing intervention?
a. Encourage oral hydration
b. Prepare for D&C
c. Administer oxytocin
d. Monitor fetal heart tones
Answer: b. Prepare for D&C
Rationale: Incomplete abortion requires D&C to remove retained products and prevent infection or hemorrhage.
57
A patient at 9 weeks gestation presents with a history of heavy bleeding and reports passing tissue. An ultrasound shows an empty uterus. What is the best nursing action?
a. Administer oxytocin to complete the process
b. Prepare for emergency D&C
c. Monitor for continued bleeding and support the patient emotionally
d. Start IV fluids for hemorrhage
Answer: c. Monitor for continued bleeding and support the patient emotionally
Rationale: In a complete abortion, all products of conception have been expelled, so no further medical treatment is needed unless bleeding continues.
58
A patient at 10 weeks gestation has had no fetal movement and no fetal heart tones on ultrasound but has had no cramping or bleeding. What is the next step?
a. Observe for spontaneous passage of tissue
b. Administer misoprostol or perform a D&C
c. Send the patient home with no intervention
d. Prepare for emergency delivery
Answer: b. Administer misoprostol or perform a D&C
Rationale: A missed abortion is when the fetus has died in utero, but products of conception remain. Medical or surgical intervention is needed.
59
A patient with a history of retained fetal tissue presents with fever, chills, foul-smelling vaginal discharge, and abdominal tenderness. What is the priority intervention?
a. Prepare for emergency D&C
b. Administer IV antibiotics
c. Start oxytocin
d. Monitor for fetal heart tones
Answer: b. Administer IV antibiotics
Rationale: Septic abortion is a life-threatening condition that requires immediate IV antibiotics and uterine evacuation.
60
A patient with three previous miscarriages is diagnosed with recurrent abortion. Which intervention is most appropriate for future pregnancies?
a. Genetic counseling and testing
b. Immediate induction of labor
c. Bed rest in the first trimester
d. Routine prenatal care without additional interventions
Answer: a. Genetic counseling and testing
Rationale: Recurrent abortion may be due to genetic abnormalities, hormonal imbalances, or uterine issues, requiring further evaluation.
61
A pregnant patient with Class III heart disease is at risk for which complication?
a. Spontaneous abortion
b. Severe limitation of physical activity
c. Increased fetal movement
d. Hypertension
Answer: b. Severe limitation of physical activity
Rationale: In Class III heart disease, the patient is symptomatic with normal activity and has marked physical limitations.
62
What is the recommended mode of delivery for a pregnant patient with Class IV heart disease?
a. Induction of labor at 37 weeks
b. Vaginal delivery with forceps assistance
c. Cesarean delivery with cardiac monitoring
d. Spontaneous labor with epidural analgesia
Answer: c. Cesarean delivery with cardiac monitoring
Rationale: Class IV patients are at high risk of cardiac failure, and a controlled cesarean delivery is often safer.
63
A pregnant patient with anemia should be encouraged to eat foods high in:
a. Vitamin C
b. Iron
c. Folic acid
d. Potassium
Answer: b. Iron
Rationale: Iron deficiency anemia is common in pregnancy and requires increased dietary iron intake.
64
What lab value confirms iron-deficiency anemia in pregnancy?
a. Hemoglobin <11 g/dL
b. Platelets <150,000
c. White blood cell count >15,000
d. Blood glucose >140 mg/dL
Answer: a. Hemoglobin <11 g/dL
Rationale: Anemia in pregnancy is diagnosed when hemoglobin falls below 11 g/dL.
65
A 32-week pregnant patient presents with gush of clear fluid, no contractions, and no fever. What is the best management?
a. Immediate induction of labor
b. Administer betamethasone and monitor for infection
c. Perform a vaginal exam
d. Discharge the patient home
Answer: b. Administer betamethasone and monitor for infection
Rationale: Preterm premature rupture of membranes (PPROM) requires corticosteroids to promote fetal lung maturity.
66
What test confirms rupture of membranes?
a. Biophysical profile
b. Fetal fibronectin test
c. Non-stress test
d. Nitrazine test and fern test
Answer: d. Nitrazine test and fern test
Rationale: Amniotic fluid turns Nitrazine paper blue, and fern patterns confirm rupture of membranes.
67
A pregnant patient with Class II heart disease is being counseled on activity levels. Which statement by the patient indicates understanding?
a. "I should avoid all physical activity and remain on bed rest."
b. "I can engage in normal activities but should stop if I feel fatigued."
c. "I can exercise as much as I did before pregnancy."
d. "I should not worry about my heart condition since it does not affect pregnancy."
Answer: b. "I can engage in normal activities but should stop if I feel fatigued."
Rationale: Class II heart disease allows for normal daily activities but may cause fatigue and mild limitations.
68
Which symptom would require immediate medical attention in a pregnant patient with Class III heart disease?
a. Mild shortness of breath after walking
b. Swelling in the feet at the end of the day
c. Cyanosis and increased shortness of breath at rest
d. Fatigue after climbing stairs
Answer: c. Cyanosis and increased shortness of breath at rest
Rationale: Severe dyspnea, cyanosis, and shortness of breath at rest indicate cardiac decompensation and require immediate intervention.
69
A pregnant patient with sickle cell anemia is admitted with severe joint pain and fever. What is the priority nursing intervention?
a. Administer IV fluids and oxygen
b. Start oxytocin to induce labor
c. Restrict all fluids
d. Perform an immediate blood transfusion
Answer: a. Administer IV fluids and oxygen
Rationale: Sickle cell crisis requires IV hydration and oxygen to prevent fetal hypoxia and maternal complications.
70
A nurse is teaching a pregnant patient with iron-deficiency anemia about iron supplements. Which statement indicates correct understanding?
a. "I should take my iron supplement with milk to increase absorption."
b. "Taking vitamin C with my iron pill can help my body absorb it better."
c. "Iron supplements will make my blood sugar levels drop."
d. "I should stop taking iron supplements once my hemoglobin reaches normal levels."
Answer: b. "Taking vitamin C with my iron pill can help my body absorb it better."
Rationale: Vitamin C enhances iron absorption, while calcium (in milk) inhibits absorption.
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72
Which finding suggests that a patient with PPROM has developed chorioamnionitis?
a. Clear amniotic fluid with no odor
b. Maternal fever, tachycardia, and uterine tenderness
c. Increased fetal movement
d. Normal white blood cell (WBC) count
Answer: b. Maternal fever, tachycardia, and uterine tenderness
Rationale: Fever, tachycardia, and foul-smelling amniotic fluid indicate infection (chorioamnionitis).
73
A nurse is educating a pregnant patient about vaccinations. Which statement is correct?
a. "I should get the MMR vaccine at my next visit."
b. "The Tdap vaccine is recommended during pregnancy."
c. "Live vaccines like varicella are safe in pregnancy."
d. "Flu shots should be avoided during pregnancy."
Answer: b. "The Tdap vaccine is recommended during pregnancy."
Rationale: Tdap (tetanus, diphtheria, pertussis) is recommended in the third trimester to protect the newborn from pertussis.
74
Which vaccine is contraindicated in pregnancy?
a. Tdap
b. Influenza (inactivated)
c. MMR
d. Hepatitis B
Answer: c. MMR
Rationale: Live vaccines (MMR, varicella, intranasal flu) are contraindicated in pregnancy due to risk of fetal harm.
75
A nurse is counseling a pregnant patient about caffeine intake. What is the maximum recommended amount per day?
a. 100 mg
b. 200 mg
c. 400 mg
d. No safe amount
Answer: b. 200 mg
Rationale: Caffeine intake should be limited to 200 mg/day to reduce the risk of preterm birth and low birth weight.
76
A newborn is irritable, has a high-pitched cry, poor feeding, and tremors. What substance was the mother most likely using during pregnancy?
a. Alcohol
b. Nicotine
c. Opioids
d. Marijuana
Answer: c. Opioids
Rationale: Neonatal abstinence syndrome (NAS) occurs in newborns exposed to opioids and causes tremors, irritability, and poor feeding.
77
A pregnant patient with a BMI of 36 is at increased risk for which complication?
a. Increased fetal iron stores
b. Gestational diabetes
c. Preterm labor
d. Rh incompatibility
Answer: b. Gestational diabetes
Rationale: Obesity increases the risk of gestational diabetes, preeclampsia, and cesarean birth.
78
What is the best dietary recommendation for an obese pregnant patient?
a. Eliminate carbohydrates
b. Follow a balanced diet with appropriate weight gain goals
c. Limit fluid intake
d. Avoid all sugar
Answer: b. Follow a balanced diet with appropriate weight gain goals
Rationale: Nutritional counseling should focus on healthy weight gain and balanced nutrition, not extreme dietary restrictions.
79
A pregnant patient with a history of a prior C-section suddenly experiences severe abdominal pain, fetal bradycardia, and loss of contractions. What is the priority action?
a. Prepare for emergency C-section
b. Start oxytocin to induce labor
c. Increase IV fluids and reposition the patient
d. Continue monitoring
Answer: a. Prepare for emergency C-section
Rationale: Uterine rupture is a life-threatening emergency requiring immediate surgical intervention.
80
Which patient is at highest risk for uterine rupture?
a. First-time mother in spontaneous labor
b. Patient with a previous classical C-section
c. Patient with placenta previa
d. Patient with gestational diabetes
Answer: b. Patient with a previous classical C-section
Rationale: A classical (vertical) C-section incision has a higher risk of rupture than a low transverse incision.
81
A Bishop Score of 8 suggests which of the following?
a. The cervix is not favorable for induction
b. The patient is in active labor
c. A successful vaginal delivery is likely with induction
d. The patient requires a cesarean section
Answer: c. A successful vaginal delivery is likely with induction
82
Which Bishop Score factor assesses fetal descent?
a. Dilation
b. Effacement
c. Station
d. Consistency
Answer: c. Station
Rationale: Station refers to how far the fetal head has descended into the pelvis (measured in relation to ischial spines).
83
A nurse is assessing a laboring patient’s cervix and documents 3 cm dilated, 70% effaced, and -2 station. What does the station indicate?
a. The fetal head is above the ischial spines
b. The cervix is fully dilated
c. The baby is crowning
d. The cervix is not yet effaced
Answer: a. The fetal head is above the ischial spines
Rationale: Station -2 means the fetal head is still above the ischial spines.
84
What does 100% effacement mean?
a. The cervix has fully opened
b. The cervix is completely thinned out
c. The patient is ready for a cesarean delivery
d. The baby is engaged in the pelvis
Answer: b. The cervix is completely thinned out
Rationale: Effacement refers to cervical thinning, which is needed before full dilation.
85
What event marks the start of the second stage of labor?
a. Complete cervical dilation
b. Rupture of membranes
c. Engagement of the fetal head
d. Crowning of the baby’s head
Answer: a. Complete cervical dilation
Rationale: The second stage begins at 10 cm dilation and ends with delivery of the baby.
86
During which stage of labor is the placenta delivered?
a. First stage
b. Second stage
c. Third stage
d. Fourth stage
Answer: c. Third stage
Rationale: The third stage is from birth of the baby to placenta expulsion.
87
What does the bloody show indicate?
a. Placental abruption
b. Cervical dilation is occurring
c. Membrane rupture
d. Postpartum hemorrhage
Answer: b. Cervical dilation is occurring
Rationale: The bloody show is the release of the mucus plug, a sign of cervical change.
88
A patient reports pink-tinged vaginal discharge at 38 weeks. What is the best nursing response?
a. “This is a sign of labor approaching.”
b. “You need an immediate C-section.”
c. “This is a sign of uterine rupture.”
d. “You must go to the hospital immediately.”
Answer: a. “This is a sign of labor approaching.”
Rationale: Bloody show is normal in late pregnancy and indicates the cervix is softening.
89
Which "P" of labor refers to uterine contractions?
a. Passenger
b. Passageway
c. Powers
d. Psychological factors
Answer: c. Powers
Rationale: Powers refer to contractions and maternal pushing efforts.
90
The fetus and its position in the uterus fall under which “P” of labor?
a. Powers
b. Passenger
c. Position
d. Psychological response
Answer: b. Passenger
Rationale: The passenger refers to the fetus, its presentation, and its size.
91
What is the priority action after spontaneous rupture of membranes?
a. Check maternal temperature
b. Assess fetal heart rate
c. Prepare for immediate delivery
d. Perform a cervical exam
Answer: b. Assess fetal heart rate
Rationale: Umbilical cord prolapse is a risk after ROM, making FHR assessment priority.
92
A patient asks about artificial rupture of membranes (amniotomy). Which statement is correct?
a. It will speed up contractions
b. It is done at any stage of labor
c. It is the first step in labor induction
d. It is a last resort if labor is prolonged
Answer: a. It will speed up contractions
Rationale: Amniotomy releases prostaglandins, which help stimulate contractions.
93
A nurse is preparing a 39-week pregnant patient for labor induction. Which medication will most likely be administered first to ripen the cervix?
a. Oxytocin (Pitocin)
b. Misoprostol (Cytotec)
c. Terbutaline
d. Methotrexate
Answer: b. Misoprostol (Cytotec)
Rationale: Misoprostol and dinoprostone are used to soften and dilate the cervix before starting oxytocin for induction.
94
Which of the following is a mechanical method of cervical ripening?
a. Oxytocin infusion
b. Foley balloon catheter
c. Prostaglandin gel
d. Artificial rupture of membranes
Answer: b. Foley balloon catheter
Rationale: A Foley catheter applies pressure on the cervix, helping it dilate mechanically without medication.
95
Which factor is not included in the Bishop Score?
a. Fetal heart rate
b. Cervical dilation
c. Effacement
d. Fetal station
Answer: a. Fetal heart rate
Rationale: The Bishop Score evaluates dilation, effacement, station, cervical consistency, and cervical position, but not fetal heart rate.
96
A patient in active labor is 5 cm dilated, 80% effaced, and at 0 station. What does the station indicate?
a. The baby is crowning
b. The fetal head is at the level of the ischial spines
c. The cervix is completely dilated
d. The fetal head is above the pelvis
Answer: b. The fetal head is at the level of the ischial spines
Rationale: 0 station means the fetal head is engaged and aligned with the ischial spines.
97
A patient asks what 100% effacement means. The nurse responds:
a. "The cervix has completely thinned out."
b. "You are ready to push the baby out."
c. "You will need a cesarean delivery."
d. "Your contractions are ineffective."
Answer: a. "The cervix has completely thinned out."
Rationale: Effacement refers to the thinning of the cervix; 100% effaced means the cervix is fully thinned.
98
What marks the beginning of the second stage of labor?
a. Full cervical dilation
b. Engagement of the fetal head
c. Complete effacement
d. Rupture of membranes
Answer: a. Full cervical dilation
Rationale: The second stage starts when the cervix is fully dilated at 10 cm and ends with delivery of the baby.
99
Which of the following occurs in the third stage of labor?
a. Fetal descent into the birth canal
b. Cervical dilation from 0-10 cm
c. Delivery of the placenta
d. Expulsion of amniotic fluid
Answer: c. Delivery of the placenta
Rationale: The third stage of labor lasts from delivery of the baby to placenta expulsion.
100
What does the bloody show indicate?
a. Placental abruption
b. Cervical dilation and labor progression
c. Uterine rupture
d. Postpartum hemorrhage
Answer: b. Cervical dilation and labor progression
Rationale: The bloody show is the release of the mucus plug, a sign of cervical change before labor.
101
A patient at 38 weeks reports pink-tinged vaginal discharge. What should the nurse say?
a. "This is a normal sign that labor may begin soon."
b. "You need an immediate C-section."
c. "This means you are in active labor."
d. "You should go to the hospital right now."
Answer: a. "This is a normal sign that labor may begin soon."
Rationale: Bloody show is normal in late pregnancy and indicates cervical softening and early labor changes.
102
What is the priority action after spontaneous rupture of membranes (SROM)?
a. Check maternal temperature
b. Assess fetal heart rate
c. Prepare for immediate delivery
d. Perform a cervical exam
Answer: b. Assess fetal heart rate
Rationale: Umbilical cord prolapse is a risk after ROM, so FHR assessment is priority.
103
A postpartum nurse is assessing a patient 24 hours after delivery. Where should the fundus be located?
a. 2 cm above the umbilicus
b. At the level of the umbilicus
c. 2 cm below the umbilicus
d. Not palpable
Answer: c. 2 cm below the umbilicus
Rationale: The fundus descends 1 cm per day after birth and should be 2 cm below the umbilicus on day 2 postpartum.
104
A nurse is concerned about subinvolution in a patient two weeks postpartum. Which symptom supports this diagnosis?
a. Lochia that remains bright red
b. Fundus at the symphysis pubis
c. Fundus firm and midline
d. Increased milk production
Answer: a. Lochia that remains bright red
Rationale: Persistent bright red bleeding and a uterus that is not involuting properly are signs of subinvolution, often due to infection or retained placenta.
105
A postpartum patient is tachycardic (HR 120) and hypotensive (BP 90/50). What is the nurse's priority action?
a. Encourage ambulation
b. Monitor for signs of hemorrhage
c. Reassess in one hour
d. Check for urinary retention
Answer: b. Monitor for signs of hemorrhage
Rationale: Tachycardia and hypotension are early signs of hypovolemic shock, requiring immediate PPH assessment.
106
A postpartum patient has difficulty urinating after a vaginal delivery. What is the nurse’s best intervention?
a. Encourage ambulation and hydration
b. Insert a urinary catheter immediately
c. Administer oxytocin to promote uterine contraction
d. Increase IV fluids
Answer: a. Encourage ambulation and hydration
Rationale: Postpartum urinary retention is common due to bladder trauma and epidural use. Encouraging natural voiding is the first-line intervention before catheterization.
107
A postpartum patient is diagnosed with endometritis. Which symptom is most concerning?
a. Foul-smelling lochia
b. Mild cramping
c. Increased thirst
d. Pink vaginal discharge
Answer: a. Foul-smelling lochia
Rationale: Endometritis is a uterine infection, and foul-smelling lochia is a major warning sign.
108
A postpartum patient presents with fever, chills, and a swollen, red breast. What condition does this indicate?
a. Mastitis
b. Engorgement
c. Blocked milk duct
d. Postpartum hemorrhage
Answer: a. Mastitis
Rationale: Mastitis is an infection of breast tissue, often caused by milk stasis and bacteria entering through cracked nipples.
109
A postpartum patient reports severe headache and blurred vision. What is the priority action?
a. Assess for postpartum preeclampsia
b. Encourage hydration
c. Administer ibuprofen
d. Monitor vital signs and reassess in 30 minutes
Answer: a. Assess for postpartum preeclampsia
Rationale: Postpartum preeclampsia can occur up to six weeks after delivery and requires immediate medical attention.
110
A patient at 4 weeks postpartum reports passing large blood clots. What is the best nursing response?
a. "Clots are normal up to 6 weeks postpartum."
b. "You need to come in immediately for evaluation."
c. "Increase your fluid intake."
d. "Monitor your temperature at home."
Answer: b. "You need to come in immediately for evaluation."
Rationale: Passing large clots at 4 weeks may indicate retained placental fragments or late postpartum hemorrhage (PPH).
111
A post-op C-section patient reports a swollen, warm incision site. What is the nurse’s priority action?
a. Reassure the patient that mild swelling is normal
b. Assess for wound infection and notify the provider
c. Encourage bed rest
d. Administer oxytocin
Answer: b. Assess for wound infection and notify the provider
Rationale: Swelling, warmth, and redness at the incision site may indicate infection, requiring further assessment and antibiotics.
112
What is the best method to prevent complications after a C-section?
a. Ambulate within 6-12 hours post-surgery
b. Stay in bed for 24 hours
c. Restrict fluid intake
d. Avoid pain medication
Answer: a. Ambulate within 6-12 hours post-surgery
Rationale: Early ambulation prevents DVT, promotes bowel function, and reduces complications.
113
Which uterotonic medication is contraindicated in hypertensive patients?
a. Oxytocin (Pitocin)
b. Methylergonovine (Methergine)
c. Carboprost (Hemabate)
d. Misoprostol (Cytotec)
Answer: b. Methylergonovine (Methergine)
Rationale: Methergine causes vasoconstriction, which can worsen hypertension.
114
What is the first-line treatment for uterine atony leading to postpartum hemorrhage?
a. Perform fundal massage
b. Start IV fluids
c. Administer oxytocin (Pitocin)
d. Insert a Bakri balloon
Answer: a. Perform fundal massage
Rationale: Fundal massage stimulates the uterus to contract and is the first-line intervention for PPH.
115
A patient has been in labor for 12 hours with no cervical change. What is the most likely cause?
a. Precipitous labor
b. Labor dystocia
c. Uterine rupture
d. Umbilical cord prolapse
Answer: b. Labor dystocia
Rationale: Labor dystocia occurs when labor progresses abnormally slow due to ineffective contractions.
116
A nurse recognizes shoulder dystocia when:
a. The baby’s head delivers, but the shoulders remain stuck
b. The umbilical cord prolapses
c. The baby is born rapidly without resistance
d. The mother experiences uterine rupture
Answer: a. The baby’s head delivers, but the shoulders remain stuck
Rationale: Shoulder dystocia occurs when the fetal shoulders are trapped behind the pubic bone.
117
Which of the following vital signs would be expected in a healthy newborn?
a. Heart rate 90 bpm, temperature 96.8°F, respirations 50 breaths per minute
b. Heart rate 160 bpm, temperature 98.6°F, respirations 40 breaths per minute
c. Heart rate 70 bpm, temperature 100.4°F, respirations 65 breaths per minute
d. Heart rate 180 bpm, temperature 99.5°F, respirations 25 breaths per minute
Answer: b. Heart rate 160 bpm, temperature 98.6°F, respirations 40 breaths per minute
Rationale: Newborn vital signs include HR 110-160 bpm, RR 30-60, Temp 97.7-99.5°F (36.5-37.5°C).
117
A nurse is assessing a newborn 30 minutes after birth. Which vital sign finding requires immediate intervention?
a. Heart rate of 140 bpm
b. Respiratory rate of 72 breaths per minute
c. Axillary temperature of 97.7°F (36.5°C)
d. Oxygen saturation of 95%
Answer: b. Respiratory rate of 72 breaths per minute
Rationale: Normal newborn respiratory rate is 30-60 breaths per minute. Tachypnea may indicate respiratory distress syndrome (RDS) or transient tachypnea of the newborn (TTN).
118
A nurse places a newborn under a radiant warmer. What is the primary reason for this intervention?
a. To prevent brown fat metabolism
b. To help the baby digest formula
c. To promote urinary output
d. To improve circulation
Answer: a. To prevent brown fat metabolism
Rationale: Newborns cannot shiver, so they rely on brown fat metabolism for heat. Preventing cold stress reduces metabolic demands.
119
Which intervention is the most effective in preventing newborn heat loss by convection?
a. Wrapping the infant in a warm blanket
b. Placing the infant in a heated isolette
c. Keeping the room temperature at 72°F (22°C)
d. Drying the infant immediately after birth
Answer: b. Placing the infant in a heated isolette
Rationale: Convection heat loss occurs when heat transfers to air. A heated isolette prevents loss to cold surrounding air.
120
What is the primary reason newborns are at risk for hyperbilirubinemia?
a. Delayed passage of meconium
b. Increased production of fetal hemoglobin
c. Lack of albumin in the bloodstream
d. Immature liver function
Answer: d. Immature liver function
Rationale: The newborn’s liver is immature and has a reduced ability to conjugate bilirubin, leading to jaundice.
121
A breastfeeding infant develops jaundice on day 3 of life. What is the most likely cause?
a. Breast milk jaundice
b. Delayed meconium passage
c. Pathologic jaundice
d. Neonatal sepsis
Answer: a. Breast milk jaundice
Rationale: Breastfeeding jaundice appears within 2-4 days due to lower milk intake. It resolves with frequent feeding.
122
A newborn has not passed meconium within 48 hours of birth. What condition should the nurse suspect?
a. Necrotizing enterocolitis
b. Meconium aspiration syndrome
c. Hirschsprung’s disease
d. Transient tachypnea of the newborn
Answer: c. Hirschsprung’s disease
Rationale: Delayed meconium passage may indicate Hirschsprung’s disease (a lack of ganglion cells in the intestines).
123
A nurse is assessing a newborn’s neurological function. Which finding is abnormal?
a. Presence of the Moro reflex
b. Weak, high-pitched cry
c. Positive rooting reflex
d. Flexed posture with spontaneous movements
Answer: b. Weak, high-pitched cry
Rationale: A weak or high-pitched cry may indicate neurological impairment, hypoxia, or increased intracranial pressure.
124
The nurse observes a newborn sleeping 2 hours after birth. This is most consistent with which period of reactivity?
a. First period of reactivity
b. Second period of reactivity
c. Deep sleep phase
d. Active sleep phase
Answer: b. Second period of reactivity
Rationale: Newborns enter a "period of decreased responsiveness" after the first reactivity period, lasting 60-100 minutes.
125
Which behavior suggests a healthy newborn response to external stimuli?
a. Turning away from a bright light
b. Flaccid posture with minimal movement
c. Irregular breathing with nasal flaring
d. Continuous crying for 3 hours
Answer: a. Turning away from a bright light
Rationale: Newborns demonstrate orientation and habituation by responding to stimuli (e.g., turning from bright lights).
126
A newborn’s 1-minute Apgar score is 4. What is the priority nursing action?
a. Provide skin-to-skin contact with the mother
b. Administer oxygen and stimulate the infant
c. Reassess in 5 minutes
d. Initiate formula feeding
Answer: b. Administer oxygen and stimulate the infant
Rationale: An Apgar score of 4 indicates moderate distress. Immediate interventions include oxygen, stimulation, and possibly resuscitation.
127
Which Apgar score represents a healthy newborn at 5 minutes of life?
a. 1
b. 4
c. 6
d. 7
Answer: d. 7
Rationale: An Apgar score of 7-10 at 5 minutes is considered normal. Lower scores indicate respiratory distress or asphyxia.
128
Which reflex should disappear by 4 months of age?
a. Moro reflex
b. Babinski reflex
c. Rooting reflex
d. Plantar grasp reflex
Answer: a. Moro reflex
Rationale: The Moro reflex (startle reflex) disappears by 4-6 months.
129
A 36-week gestation newborn is assessed using the Ballard Score. What finding is expected?
a. Abundant lanugo
b. Creases covering entire foot
c. Firm ear cartilage
d. Thick vernix caseosa
Answer: a. Abundant lanugo
Rationale: Preterm infants (34-36 weeks) have excess lanugo, thin skin, and few foot creases.
130
The nurse is assessing a newborn’s reflexes during a routine examination. Which of the following findings should the nurse recognize as abnormal and requires further evaluation?
A) The infant turns their head and opens their mouth when the nurse strokes their cheek.
B) The infant extends their arms, spreads their fingers, and then retracts them when startled by a loud noise.
C) The infant’s toes fan outward when the sole of the foot is stroked from the heel to the toes.
D) The infant does not grasp the nurse’s finger when placed in the palm of their hand.
D) The infant does not grasp the nurse’s finger when placed in the palm of their hand.
Rooting Reflex (A): This is a normal reflex where the newborn turns their head and opens their mouth when the cheek is stroked, preparing them for feeding. It typically disappears around 3-4 months.
Moro Reflex (B): Also called the "startle reflex," this is a normal response where the newborn extends the arms, spreads the fingers, and then brings them back when startled. It is present from birth and disappears by 4-6 months.
Babinski Reflex (C): A normal finding in newborns where the toes fan outward when the sole is stroked. This reflex disappears by 12 months.
Palmar Grasp Reflex (D): Normally, when the nurse places a finger in the infant’s palm, the baby should grasp it tightly. This reflex is present from birth and disappears by 3-6 months.
🚨 An absent palmar grasp reflex could indicate a neurological impairment, nerve damage, or muscle weakness and requires further evaluation. 🚨
131
A newborn is classified as Small for Gestational Age (SGA). Which maternal condition is a risk factor for SGA?
a. Gestational diabetes
b. Preeclampsia
c. Rh incompatibility
d. Polyhydramnios
Answer: b. Preeclampsia
Rationale: Preeclampsia causes placental insufficiency, leading to intrauterine growth restriction (IUGR) and SGA.
132
A SGA newborn is at risk for which complication?
a. Hyperglycemia
b. Hyperbilirubinemia
c. Hypoglycemia
d. Polyhydramnios
Answer: c. Hypoglycemia
Rationale: SGA newborns have low glycogen stores and are prone to hypoglycemia. Early feeding is essential.
133
A newborn has a hematocrit level of 68%. The nurse knows this indicates:
a. Anemia
b. Polycythemia
c. Hypoxia
d. Hyperbilirubinemia
Answer: b. Polycythemia
Rationale: Hematocrit >65% in newborns indicates polycythemia, which increases the risk of hyperbilirubinemia and clotting disorders.
134
Which is a common cause of preterm birth?
a. Post-term pregnancy
b. Intrauterine infection
c. Large for gestational age (LGA)
d. Placenta previa
Answer: b. Intrauterine infection
Rationale: Infections like chorioamnionitis can trigger preterm labor due to inflammation and premature rupture of membranes.
135
A preterm newborn is at risk for respiratory distress due to:
a. Excess surfactant production
b. Immature alveoli
c. Delayed liver function
d. Increased muscle tone
Answer: b. Immature alveoli
Rationale: Preterm infants have fewer alveoli and decreased surfactant, leading to respiratory distress.
136
What nursing intervention is most effective in reducing respiratory complications in a preterm newborn?
a. Early bottle feeding
b. Skin-to-skin contact
c. Administering exogenous surfactant
d. Delayed cord clamping
Answer: c. Administering exogenous surfactant
Rationale: Surfactant therapy improves lung compliance in preterm infants, reducing the risk of Respiratory Distress Syndrome (RDS).
137
A nurse is caring for a preterm infant under a radiant warmer. What is the priority nursing action?
a. Assess blood glucose levels
b. Monitor for dehydration
c. Check the temperature frequently
d. Encourage kangaroo care
Answer: c. Check the temperature frequently
Rationale: Preterm infants are at risk for cold stress due to their thin skin and lack of brown fat.
138
What is the best feeding option for a preterm newborn unable to coordinate sucking and swallowing?
a. Breastfeeding on demand
b. NG tube feeding
c. Bottle feeding with formula
d. IV fluids only
Answer: b. NG tube feeding
Rationale: Gavage (NG tube) feeding is used when infants cannot suck/swallow effectively but still need enteral nutrition.
139
A parent of a preterm infant expresses fear of handling their baby in the NICU. What is the nurse's best response?
a. "Your baby is too fragile to be touched right now."
b. "We can teach you how to do skin-to-skin care."
c. "Don't worry, the nurses will do everything."
d. "You can take your baby home earlier if you avoid handling."
Answer: b. "We can teach you how to do skin-to-skin care."
Rationale: Kangaroo care improves bonding, promotes thermoregulation, and empowers parents.
140
What is an effective strategy to promote developmental care for preterm infants?
a. Minimizing environmental noise and light
b. Encouraging frequent handling
c. Avoiding parental interaction
d. Providing rigid feeding schedules
Answer: a. Minimizing environmental noise and light
Rationale: Preterm infants are sensitive to stimulation. Reducing light and noise supports neurodevelopment.
141
A postpartum patient reports feeling sad, fatigued, and tearful for the past 2 weeks. What is the best response by the nurse?
a. "These feelings are normal and will go away soon."
b. "I’ll refer you to a postpartum depression specialist."
c. "Try to rest and drink more fluids."
d. "This is postpartum psychosis, and you need hospitalization."
Answer: b. "I’ll refer you to a postpartum depression specialist."
Rationale: Postpartum depression lasts longer than baby blues and requires early intervention.
142
Which symptom requires immediate intervention in a patient with suspected postpartum psychosis?
a. Crying spells
b. Difficulty sleeping
c. Hallucinations and delusions
d. Low energy levels
Answer: c. Hallucinations and delusions
Rationale: Postpartum psychosis is a medical emergency that requires hospitalization and psychiatric care.
143
Which car seat safety rule is correct for a newborn?
a. Use a forward-facing car seat.
b. Place the car seat in the front seat for easy monitoring.
c. Use a rear-facing car seat in the back seat.
d. Position the baby at a 90-degree angle.
Answer: c. Use a rear-facing car seat in the back seat.
Rationale: Newborns should always be in a rear-facing car seat in the back seat to reduce injury risk.
144
What is the best way to prevent sudden infant death syndrome (SIDS)?
a. Place the baby on their back to sleep
b. Co-sleep with the baby
c. Use loose blankets in the crib
d. Keep the baby in a sitting position while sleeping
Answer: a. Place the baby on their back to sleep
Rationale: The "Back to Sleep" campaign reduced SIDS rates significantly. Infants should sleep on a firm mattress with no loose bedding.
145
A nurse is assessing fetal heart rate (FHR) variability. Which finding is considered normal (reassuring)?
a. Absent variability
b. Minimal variability (0-5 bpm change)
c. Moderate variability (6-25 bpm change)
d. Marked variability (>25 bpm change)
Answer: c. Moderate variability (6-25 bpm change)
Rationale: Moderate variability indicates a well-oxygenated fetus and normal autonomic nervous system function.
146
What condition is most likely associated with absent FHR variability?
a. Fetal movement
b. Fetal hypoxia or acidosis
c. Maternal hydration status
d. Contractions occurring every 5 minutes
Answer: b. Fetal hypoxia or acidosis
Rationale: Absent variability suggests fetal distress, hypoxia, or acidosis, requiring immediate intervention.
147
A nurse observes a 15 bpm increase in FHR lasting 20 seconds in a term fetus. What is the correct interpretation?
a. Acceleration, a reassuring finding
b. Early deceleration, requiring monitoring
c. Variable deceleration, a sign of cord compression
d. Prolonged deceleration, indicating fetal distress
Answer: a. Acceleration, a reassuring finding
Rationale: An acceleration is a temporary FHR increase, which indicates fetal well-being and normal oxygenation.
148
What is the expected response in a reactive Non-Stress Test (NST) at 32 weeks?
a. Two FHR accelerations of 15 bpm for at least 15 seconds in 20 minutes
b. Minimal variability with early decelerations
c. Recurrent late decelerations
d. Baseline bradycardia with occasional accelerations
Answer: a. Two FHR accelerations of 15 bpm for at least 15 seconds in 20 minutes
Rationale: A reactive NST confirms fetal well-being and intact oxygenation.
149
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150
A fetal heart tracing shows decelerations that mirror contractions. What is the correct interpretation?
a. Early decelerations caused by fetal head compression
b. Variable decelerations caused by cord compression
c. Late decelerations indicating placental insufficiency
d. Prolonged decelerations requiring immediate delivery
Answer: a. Early decelerations caused by fetal head compression
Rationale: Early decelerations are benign and mirror contractions due to vagal stimulation from head compression.
151
A Category III FHR tracing includes which finding?
a. Moderate variability with early decelerations
b. Absent variability with recurrent late decelerations
c. Accelerations with normal baseline
d. Mild variable decelerations with moderate variability
Answer: b. Absent variability with recurrent late decelerations
Rationale: Category III indicates fetal distress and requires immediate intervention (e.g., intrauterine resuscitation or delivery).
152
What is the best nursing action for a Category III tracing with recurrent late decelerations?
a. Reassess in 30 minutes
b. Continue routine monitoring
c. Initiate intrauterine resuscitation (LIONS)
d. Prepare for discharge
Answer: c. Initiate intrauterine resuscitation (LIONS)
Rationale: Category III tracings require immediate intervention, including repositioning, oxygen, IV fluids, and stopping Pitocin.
153
A nurse reviews a fetal heart tracing and notes a sawtooth pattern with rapid fluctuations. What is the correct interpretation?
a. Variable decelerations
b. Sinusoidal pattern, indicating fetal anemia
c. Late decelerations, requiring intervention
d. Early decelerations, expected in active labor
Answer: b. Sinusoidal pattern, indicating fetal anemia
Rationale: A sinusoidal pattern is an ominous sign associated with fetal anemia or severe fetal compromise.
154
The nurse observes a fetal heart tracing with abrupt drops and quick recoveries. What is the most likely cause?
a. Placental insufficiency
b. Fetal head compression
c. Umbilical cord compression
d. Maternal hypotension
Answer: c. Umbilical cord compression
Rationale: Variable decelerations (abrupt dips) are caused by cord compression and may require amnioinfusion.
155
What is the correct sequence for intrauterine resuscitation (LIONS)?
a. Lateral position, IV fluids, Oxygen, Notify provider, Stop Pitocin
b. Oxygen, Notify provider, Lateral position, Stop Pitocin, IV fluids
c. Stop Pitocin, IV fluids, Notify provider, Oxygen, Lateral position
d. Lateral position, Stop Pitocin, Notify provider, IV fluids, Oxygen
Answer: a. Lateral position, IV fluids, Oxygen, Notify provider, Stop Pitocin
Rationale: LIONS (Left lateral position, IV fluids, Oxygen, Notify provider, Stop Pitocin) improves fetal oxygenation.
156
Which intervention is not part of LIONS but may be used for recurrent variable decelerations?
a. Amnioinfusion
b. Maternal repositioning
c. IV fluid bolus
d. Supplemental oxygen
Answer: a. Amnioinfusion
Rationale: Amnioinfusion (infusing fluid into the uterus) relieves cord compression, specifically for variable decelerations.
157
How should the frequency of uterine contractions be measured?
a. From the end of one contraction to the beginning of the next
b. From the peak of one contraction to the peak of the next
c. From the beginning of one contraction to the beginning of the next
d. From the duration of each contraction
Answer: c. From the beginning of one contraction to the beginning of the next
Rationale: Contraction frequency is timed from the start of one contraction to the start of the next.
158
A nurse notes a patient has six contractions in 10 minutes. What is the correct interpretation?
a. Normal contraction pattern
b. Tachysystole requiring intervention
c. Prolonged contractions
d. Hypotonic contractions
Answer: b. Tachysystole requiring intervention
Rationale: More than five contractions in 10 minutes (averaged over 30 minutes) is tachysystole and can cause fetal distress.
