Download NSG 2500 Nsg2500 Maternal-Infant Nursing Care Final Exam Questions And Correct Answers (Ve and more Exams Nursing in PDF only on Docsity!
NSG 2500 Nsg2500 Maternal-Infant Nursing Care Final
Exam Questions And Correct Answers (Verified Answers)
Plus Rationales 2025 Q&A | Instant Download PDF
The questions are NCLEX-style, covering antepartum, intrapartum, postpartum, and newborn care.
1. A pregnant client in her third trimester reports severe right upper quadrant pain, nausea, and visual disturbances. What condition does the nurse suspect? A. Hyperemesis gravidarum B. Placenta previa C. HELLP syndrome D. Gestational diabetes Rationale: HELLP syndrome is characterized by Hemolysis, Elevated Liver enzymes, and Low Platelets. RUQ pain, nausea, and visual changes are key signs. 2. A nurse is teaching a pregnant client about danger signs during pregnancy. Which of the following should the nurse include? A. Leg cramps at night B. Vaginal bleeding C. Increased urinary frequency D. Heartburn Rationale: Vaginal bleeding may indicate miscarriage or placental problems and should be reported immediately.
3. Which of the following newborn findings should be reported to the provider immediately? A. Positive Babinski reflex B. Central cyanosis C. Overlapping sutures D. Lanugo on the shoulders Rationale: Central cyanosis indicates poor oxygenation and requires immediate medical evaluation. 4. A client in labor has late decelerations on the fetal monitor. What is the nurse’s priority action? A. Reposition the client on her left side B. Perform a vaginal exam C. Increase oxytocin D. Prepare for delivery Rationale: Repositioning improves uteroplacental blood flow and oxygen delivery to the fetus. 5. A mother asks why her newborn received a vitamin K injection. What is the best response? A. "It helps the baby digest milk." B. "It prevents jaundice." C. "It helps the blood clot properly." D. "It boosts the immune system." Rationale: Newborns lack intestinal flora to produce vitamin K, needed for clotting factor synthesis.
9. Which of the following is a priority assessment after an amniotomy? A. Maternal temperature B. Cervical dilation C. Maternal blood pressure D. Fetal heart rate Rationale: Rupture of membranes can cause cord prolapse; FHR should be assessed immediately. 10. What is the purpose of administering Rho(D) immune globulin? A. Prevent Rh sensitization in an Rh-negative mother B. Increase hemoglobin levels C. Prevent gestational diabetes D. Treat hypertension Rationale: RhoGAM prevents the formation of antibodies in Rh-negative mothers exposed to Rh-positive fetal blood. 11. Which assessment indicates a positive sign of pregnancy? A. Amenorrhea B. Nausea and vomiting C. Quickening D. Fetal heartbeat by Doppler Rationale: Hearing a fetal heartbeat is an objective, positive sign of pregnancy. 12. A newborn has a respiratory rate of 68/min shortly after birth. What should the nurse do? A. Apply oxygen
B. Perform suctioning C. Monitor and reassess in one hour D. Initiate positive pressure ventilation Rationale: A respiratory rate of 60–70 in the first hour after birth may be normal transitional tachypnea.
13. Which finding is expected in a 2-day-old breastfed newborn? A. No weight loss B. Weight loss of 5% C. Weight gain of 5% D. Meconium stools have ceased Rationale: Newborns may lose up to 10% of birth weight in the first few days. 14. Which position is best for a laboring client with a prolapsed umbilical cord? A. Lithotomy B. Supine with knees flexed C. Sitting upright D. Knee-chest Rationale: The knee-chest position helps reduce pressure on the prolapsed cord and improve circulation. 15. What instruction should be included for a mother bottle-feeding her infant? A. Warm formula in the microwave B. Hold the baby semi-upright while feeding C. Add cereal to the bottle at night D. Reuse leftover formula within 6 hours
Rationale: Excessive lochia (hemorrhage) is a medical emergency and must be addressed immediately.
19. A newborn's APGAR score at 1 minute is 6. What is the appropriate action? A. No action is needed B. Begin chest compressions C. Provide oxygen and stimulation D. Intubate immediately Rationale: A score of 6 indicates moderate distress; stimulation and oxygen are appropriate initial interventions. 20. A nurse is caring for a newborn with a cephalohematoma. What should the nurse expect? A. It does not cross suture lines B. It resolves in 1–2 hours C. It requires surgical drainage D. It indicates brain damage Rationale: A cephalohematoma is a collection of blood that does not cross suture lines and resolves over weeks. 21. Which finding in a pregnant woman is most concerning? A. Mild pedal edema B. Shortness of breath with exertion C. Craving for ice D. Severe headache and visual changes
Rationale: These symptoms may indicate preeclampsia, which is a serious hypertensive disorder of pregnancy.
22. What hormone maintains the uterine lining during early pregnancy? A. Estrogen B. Progesterone C. Oxytocin D. Prolactin Rationale: Progesterone supports the endometrium, allowing for implantation and early pregnancy maintenance. 23. Which is the most reliable method of contraception? A. Diaphragm B. Intrauterine device (IUD) C. Condom D. Rhythm method Rationale: IUDs are over 99% effective, making them one of the most reliable reversible contraceptive methods. 24. A client at 36 weeks’ gestation has polyhydramnios. Which fetal condition is associated with this? A. Down syndrome B. Esophageal atresia C. Cardiac defect D. Clubfoot Rationale: Esophageal atresia prevents fetal swallowing, leading to excessive amniotic fluid.
A. Prematurity B. Macrosomia C. Full-term birth D. Vaginal delivery Rationale: Premature lungs may lack sufficient surfactant, increasing risk for RDS.
29. A nurse observes a postpartum woman with boggy uterus and heavy lochia. What is the priority action? A. Notify the provider B. Check vital signs C. Massage the fundus D. Insert a catheter Rationale: Fundal massage stimulates uterine contraction to reduce postpartum bleeding. 30. What indicates effective phototherapy in a jaundiced newborn? A. Decreased stool frequency B. Decreased bilirubin levels C. Pale skin tone D. Increased urine concentration Rationale: Phototherapy breaks down bilirubin, which is then excreted, lowering serum bilirubin. 31. What is the primary purpose of the non-stress test (NST)? A. Assess uterine activity B. Evaluate fetal oxygenation and well-being
C. Determine fetal position D. Detect uterine rupture Rationale: NST assesses fetal heart rate patterns in response to movement, indicating well-being.
32. A pregnant woman complains of calf pain and swelling. What is the nurse’s priority action? A. Apply heat B. Massage the area C. Notify the provider immediately D. Encourage ambulation Rationale: These are signs of DVT, a potentially life-threatening condition that requires prompt evaluation. 33. When should a woman receive her rubella vaccine postpartum? A. Before discharge if breastfeeding B. If she's Rh-positive C. If non-immune, before hospital discharge D. During early labor Rationale: Non-immune mothers should receive the MMR vaccine postpartum to prevent future infections. 34. A newborn is small for gestational age (SGA). What is a common complication? A. Hyperbilirubinemia B. Macrosomia C. Hypoglycemia
D. Fibrocystic changes Rationale: Mastitis presents with pain, redness, and systemic symptoms such as fever.
38. A nurse is assessing fetal heart tones with moderate variability and accelerations. What is the interpretation? A. Reassuring pattern B. Non-reassuring pattern C. Absent variability D. Bradycardia Rationale: Moderate variability and accelerations indicate good fetal oxygenation. 39. Which client is most at risk for postpartum hemorrhage? A. First-time mother B. Client with a term spontaneous vaginal birth C. Client with a history of uterine atony D. Client with hypertension Rationale: Uterine atony is the most common cause of PPH; history increases recurrence risk. 40. A newborn's axillary temperature is 96.2°F. What is the priority action? A. Notify the provider B. Administer acetaminophen C. Initiate skin-to-skin contact D. Bathe the infant Rationale: Skin-to-skin contact is the first intervention to restore thermal regulation.
41. What should the nurse do before administering magnesium sulfate for preeclampsia? A. Check glucose level B. Assess deep tendon reflexes and respiratory rate C. Measure fundal height D. Monitor fetal movement Rationale: Magnesium toxicity causes depressed reflexes and respiratory depression. 42. A woman has severe nausea, weight loss, and ketonuria in pregnancy. What condition is suspected? A. Gestational diabetes B. Hyperemesis gravidarum C. Urinary tract infection D. Preeclampsia Rationale: Hyperemesis involves severe vomiting, dehydration, and ketonuria. 43. What is the most accurate way to confirm pregnancy? A. Positive urine test B. Transvaginal ultrasound C. Presumptive symptoms D. Serum hCG Rationale: Ultrasound is the most definitive confirmation of an intrauterine pregnancy.
Rationale: Preterm infants often have thin, translucent skin and underdeveloped physical features.
48. Which condition in pregnancy is a contraindication to vaginal delivery? A. Breech presentation B. Preeclampsia C. Oligohydramnios D. Complete placenta previa Rationale: Complete placenta previa covers the cervix and contraindicates vaginal birth due to hemorrhage risk. 49. What instruction is appropriate for taking oral contraceptives? A. Take at the same time daily B. Skip during menstruation C. Take with milk D. Use condoms for the first year Rationale: Taking pills consistently daily improves efficacy and prevents pregnancy. 50. What is the purpose of Leopold’s maneuvers during assessment? A. Assess fetal tone B. Determine fetal position and presentation C. Monitor contractions D. Measure fundal height Rationale: Leopold’s maneuvers help identify fetal lie, position, and presentation through abdominal palpation.
51. Which intervention is most appropriate for a client experiencing variable decelerations on the fetal monitor? A. Apply oxygen B. Prepare for cesarean section C. Reposition the client D. Increase oxytocin infusion Rationale: Variable decelerations are often caused by cord compression, and repositioning can relieve pressure. 52. A postpartum client asks when she can begin using oral contraceptives. Which response is most appropriate? A. “Immediately after delivery.” B. “If breastfeeding, wait at least 6 weeks.” C. “After your first postpartum period.” D. “Only after a pelvic exam.” Rationale: Estrogen-containing contraceptives are not recommended during early breastfeeding due to milk supply suppression. 53. Which fetal presentation is safest for vaginal delivery? A. Breech B. Shoulder C. Occiput anterior D. Frank breech Rationale: The occiput anterior position allows for optimal fetal descent through the birth canal.
A. “That’s abnormal; he should eat every 1–2 hours.” B. “That’s normal during the first 24–48 hours.” C. “You should wake him every hour.” D. “Your baby is probably dehydrated.” Rationale: Newborns often experience a sleepy phase within the first day or two after birth.
58. What is the significance of a negative contraction stress test (CST)? A. Poor fetal tolerance to contractions B. Need for induction C. Fetal well-being under stress D. Imminent delivery Rationale: A negative CST indicates the fetus can tolerate labor contractions without late decelerations. 59. What is the most appropriate action before giving an epidural? A. Check fetal heart tones B. Position the mother supine C. Administer a fluid bolus D. Monitor temperature Rationale: A fluid bolus prevents maternal hypotension, a common side effect of epidural anesthesia. 60. A newborn's APGAR score at 5 minutes is 9. What does the nurse do next? A. Call the provider B. Document the score and continue routine care C. Repeat APGAR in 30 minutes
D. Begin resuscitation Rationale: A score of 9 is excellent; routine newborn care should be continued.
61. What symptom indicates ectopic pregnancy? A. Suprapubic pain and spotting B. Cramping and increased urination C. Unilateral lower abdominal pain and shoulder pain D. Back pain and fever Rationale: Ruptured ectopic pregnancies may cause referred shoulder pain due to diaphragmatic irritation. 62. Which behavior is expected from a mother in the taking-in phase? A. Shows interest in learning infant care B. Wants to be independent C. Talks about her labor experience D. Actively seeks discharge instructions Rationale: In the taking-in phase, the mother is focused inward and may need to process the birth experience. 63. What is the best indicator of fetal lung maturity? A. Fetal movement B. Amniotic fluid volume C. Maternal weight gain D. Lecithin/sphingomyelin (L/S) ratio of 2: Rationale: An L/S ratio ≥2:1 suggests adequate surfactant production and lung maturity.
