26Question
A nurse is providing discharge instructions to a postpartum client who gave birth to a healthy term newborn 48 hours ago. Which of the following statements by the client indicates a correct understanding of normal lochia progression during the early postpartum period?
- "My lochia should remain bright red and heavier than a heavy menstrual period for the next two weeks."
- "It is expected that my lochia will change from dark red to a brownish-pink color within the first week."
- "Once I go home, my lochia should completely stop within 72 hours of delivery."
- "If my lochia suddenly turns bright red after it had turned pink, I should simply rest more and recheck in a week."
Show the answer and explanation
Answer: B. "It is expected that my lochia will change from dark red to a brownish-pink color within the first week."
Topic: Lochia progression and education
Normal lochia progression follows a predictable pattern: lochia rubra (dark red) for the first 1 to 3 days, lochia serosa (brownish-pink) from days 4 to 10, and lochia alba (whitish-yellow) from about day 10 up to 6 weeks postpartum. Therefore, transitioning to brownish-pink within the first week reflects normal involution.
Why the others are wrong
- A – Lochia rubra (bright red) typically only lasts for the first 1 to 3 days postpartum; heavy, bright red flow for two weeks indicates potential postpartum hemorrhage or subinvolution.
- C – Lochia does not stop within 72 hours; lochia discharge normally persists for several weeks (up to 4 to 6 weeks postpartum).
- D – A sudden return to bright red lochia after it has progressed to serosa or alba is a warning sign of secondary postpartum hemorrhage or excessive physical activity requiring evaluation, not just rest.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
27Question
A nurse is caring for a client at 34 weeks' gestation who is receiving terbutaline for preterm labor suppression. Which of the following assessment findings requires immediate nursing intervention?
- Maternal heart rate of 124/min
- Fetal heart rate of 145/min with moderate variability
- Client report of mild tremors and anxiety
- Uterine contractions occurring every 8 to 10 minutes
Show the answer and explanation
Answer: A. Maternal heart rate of 124/min
Topic: Terbutaline side effects and safety
Terbutaline is a beta-2 adrenergic agonist that stimulates beta-1 receptors in the heart, frequently causing significant maternal tachycardia, palpitations, and tremors. A maternal heart rate of 124/min exceeds the standard safety threshold (usually >120/min) and requires withholding the medication and notifying the provider to prevent cardiac compromise.
Why the others are wrong
- B – A fetal heart rate of 145/min with moderate variability is entirely normal and reassuring.
- C – Mild tremors and anxiety are expected beta-adrenergic side effects of terbutaline and do not warrant stopping the infusion immediately unless accompanied by chest pain or severe tachycardia.
- D – Contractions every 8 to 10 minutes indicate that the tocolytic is successfully slowing uterine activity.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
28Question
A nurse is assessing a 4-hour-old term newborn in the transitional nursery. Which clinical findings should the nurse report immediately to the healthcare provider?
Select all that apply.
- Central cyanosis while crying quietly
- Respiratory rate of 64 breaths/min with mild intercostal retractions
- Absent red reflex bilaterally
- Single transverse palmar crease on both hands
- A soft, fluid-filled scalp swelling crossing the cranial suture lines
Show the answers and explanation
Answers: A, B and C.
- A – Central cyanosis while crying quietly
- B – Respiratory rate of 64 breaths/min with mild intercostal retractions
- C – Absent red reflex bilaterally
Topic: Abnormal newborn findings requiring immediate reporting
Central cyanosis indicates systemic hypoxia and requires immediate intervention. Tachypnea (>60 breaths/min) accompanied by retractions indicates neonatal respiratory distress. An absent red reflex suggests congenital cataracts or retinoblastoma, which is an urgent ophthalmological finding.
Why the others are wrong
- D – A single transverse palmar crease is a normal variant or soft marker that does not represent an acute physiological emergency requiring immediate provider notification.
- E – Caput succedaneum crosses suture lines due to pressure and resolves spontaneously within days without acute danger.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
29Question
A laboring client at 39 weeks of gestation receiving an oxytocin infusion exhibits spontaneous rupture of membranes. The nurse notes clear amniotic fluid with variable decelerations dropping to 80 bpm lasting 60 seconds, with rapid return to baseline and moderate variability. Which initial nursing intervention is priority?
- Prepare the client for an immediate cesarean delivery.
- Discontinue the oxytocin infusion immediately.
- Reposition the client to a side-lying or knee-chest position.
- Administer terbutaline 0.25 mg subcutaneously.
Show the answer and explanation
Answer: C. Reposition the client to a side-lying or knee-chest position.
Topic: Variable decelerations and membrane rupture
Variable decelerations are caused by umbilical cord compression, which frequently occurs or worsens following rupture of membranes due to fluid loss or cord relocation. Changing the client's position to a lateral, Trendelenburg, or knee-chest position relieves pressure off the umbilical cord and is the primary nursing intervention. While oxytocin should be stopped if uterine tachysystole is present, simple variable decelerations without tachysystole first warrant maternal repositioning.
Why the others are wrong
- A – Immediate cesarean delivery is reserved for non-resuscitative fetal status or cord prolapse that does not respond to intrauterine resuscitation measures.
- B – Discontinuing oxytocin is critical if uterine tachysystole is present, but the primary mechanical cause here is cord compression following membrane rupture, making repositioning the immediate first step.
- D – Terbutaline is used to treat uterine tachysystole or hyperstimulation, not isolated variable decelerations caused by cord compression.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
30Question
A nurse is conducting a physical assessment of a term newborn 4 hours after birth. Which findings should the nurse expect as normal physiological variants?
Select all that apply.
- Small, pearly-white papules on the bridge of the newborn's nose.
- A localized area of soft tissue swelling over the occiput that crosses suture lines.
- Dark pink to red flat macules on the posterior neck and eyelids.
- A tense, fluctuant, well-demarcated swelling over one parietal bone that does not cross suture lines.
- Fine, downy hair distributed predominantly over the newborn's shoulders and back.
Show the answers and explanation
Answers: A, B, C and E.
- A – Small, pearly-white papules on the bridge of the newborn's nose.
- B – A localized area of soft tissue swelling over the occiput that crosses suture lines.
- C – Dark pink to red flat macules on the posterior neck and eyelids.
- E – Fine, downy hair distributed predominantly over the newborn's shoulders and back.
Milia (A) are normal retention cysts of sebaceous glands that resolve spontaneously. Caput succedaneum (B) is serosanguineous subcutaneous fluid accumulation that crosses suture lines due to pressure. Telangiectatic nevi or 'stork bites' (C) are common benign capillary hemangiomas that fade over time. Lanugo (E) is normal fine downy hair seen in newborns. A cephalhematoma (D) is bleeding between the skull bone and periosteum, does not cross suture lines, and requires monitoring for hyperbilirubinemia, making it a pathological variant rather than a normal expected finding.
Why the others are wrong
- D – A cephalhematoma is a collection of blood between the cranial bone and periosteum that does not cross suture lines; the breakdown of this extravasated blood places the newborn at risk for hyperbilirubinemia and jaundice.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
31Question
A nurse is caring for a client on the postpartum unit who delivered vaginally 4 hours ago. Which of the following findings require immediate intervention?
Select all that apply.
- A firm uterine fundus located 1 cm below the umbilicus and midline
- A continuous trickle of bright red blood from the vagina with a firm fundus
- Client report of severe, unrelenting rectal pressure and sharp perineal pain
- Voiding 150 mL of clear yellow urine 3 hours after catheter removal
- Temperature of 37.9°C (100.2°F) and mild diaphoresis
Show the answers and explanation
Answers: B and C.
- B – A continuous trickle of bright red blood from the vagina with a firm fundus
- C – Client report of severe, unrelenting rectal pressure and sharp perineal pain
Topic: Postpartum complications and hematoma
A continuous trickle of bright red blood despite a firm fundus strongly suggests lacerations of the cervix or vagina requiring surgical repair. Severe rectal pressure and sharp perineal pain in a postpartum client are classic indicators of a concealed perineal or vaginal hematoma, which requires immediate provider notification and intervention.
Why the others are wrong
- A – A firm fundus at the umbilicus and midline is a normal, expected finding indicating effective myometrial contraction and low risk for atonic hemorrhage.
- D – A post-void residual or initial void of 150 mL following catheter removal indicates adequate bladder emptying and function.
- E – A low-grade temperature of 37.9°C and diaphoresis in the first 24 hours are normal physiological responses to exertion and postpartum fluid elimination.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
32Question
A primigravid client at 28 weeks of gestation is scheduled for a 2-hour 75-g oral glucose tolerance test (OGTT) following a positive 1-hour screening. Which client preparation instruction is essential for the nurse to provide?
- Maintain an unrestricted diet containing at least 150 grams of carbohydrates daily for 3 days prior to the test.
- Fast for exactly 4 hours immediately before arriving at the laboratory for the blood draw.
- Consume a high-protein, zero-carbohydrate diet on the day preceding the appointment.
- Discontinue all prenatal vitamins and iron supplements 48 hours before the procedure.
Show the answer and explanation
Answer: A. Maintain an unrestricted diet containing at least 150 grams of carbohydrates daily for 3 days prior to the test.
Topic: Gestational diabetes screening preparation
To ensure accurate diagnostic results during an oral glucose tolerance test, clients must consume an unrestricted diet with at least 150 g of carbohydrates daily for 3 days prior. Low-carbohydrate diets can cause false-positive results due to impaired glucose tolerance from carbohydrate deprivation.
Why the others are wrong
- B – Fasting for only 4 hours is inadequate; an overnight fast of at least 8 hours is required prior to a glucose tolerance test.
- C – Consuming a zero-carbohydrate diet will falsely alter glucose metabolism and can lead to a false-positive diagnostic result.
- D – Prenatal vitamins and iron do not affect blood glucose levels and should not be discontinued.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
33Question
A nurse is caring for a client at 34 weeks of gestation diagnosed with mild gestational hypertension who is being evaluated for potential disease progression. Which assessment findings should the nurse recognize as indicative of severe features?
Select all that apply.
- Serum creatinine of 1.4 mg/dL
- Persistent right upper quadrant abdominal pain
- Platelet count of 120,000/uL
- Blood pressure of 160/110 mm Hg on two occasions 4 hours apart
- Visual disturbances such as scotomata or blurred vision
Show the answers and explanation
Answers: A, B, D and E.
- A – Serum creatinine of 1.4 mg/dL
- B – Persistent right upper quadrant abdominal pain
- D – Blood pressure of 160/110 mm Hg on two occasions 4 hours apart
- E – Visual disturbances such as scotomata or blurred vision
Topic: Preeclampsia severe features assessment
Preeclampsia with severe features is diagnosed when blood pressure reaches 160/110 mm Hg or higher, or when there is evidence of end-organ dysfunction. Specific severe features include elevated serum creatinine (>1.1 mg/dL), persistent right upper quadrant or epigastric pain, thrombocytopenia (platelets <100,000/uL), and cerebral/visual disturbances.
Why the others are wrong
- C – A platelet count of 120,000/uL is lower than normal but does not meet the severe preeclampsia threshold of less than 100,000/uL.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
34Question
A nurse is providing discharge instructions to a postpartum client who delivered a healthy term newborn 48 hours ago. Which statement by the client indicates an accurate understanding of normal postpartum physiological changes?
- Experiencing significant chills and shaking right after getting home is an expected sign of hormonal adjustment.
- Passing small blood clots up to the size of a plum during the first week postpartum requires immediate medical notification.
- A sudden, transient increase in urinary output during the first few days postpartum is normal as my body rids itself of excess fluids.
- My menstrual cycle will likely return within 3 weeks if I am exclusively formula-feeding my infant.
Show the answer and explanation
Answer: C. A sudden, transient increase in urinary output during the first few days postpartum is normal as my body rids itself of excess fluids.
Topic: Normal postpartum recovery and diuresis
Postpartum diuresis occurs within the first few days following birth due to the elimination of pregnancy-induced hypervolemia and extracellular fluid, resulting in profuse diaphoresis and frequent urination.
Why the others are wrong
- A – Postpartum chills immediately after birth can occur, but shaking chills occurring days later at home suggest infection rather than normal adaptation.
- B – Passing small clots is common, but large clots (larger than a plum) or heavy continuous bleeding warrant immediate provider notification.
- D – In non-lactating clients, menses typically returns within 6 to 10 weeks, not 3 weeks.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
35Question
A primigravida at 10 weeks gestation is diagnosed with a complete hydatidiform mole via ultrasound and is scheduled for a suction curettage. Which essential postoperative instruction should the nurse include in the discharge teaching plan?
- Attempt pregnancy again within 3 months to normalize hormone levels.
- Use a reliable barrier method of contraception for the next 6 to 12 months.
- Report a sudden decrease in vaginal bleeding immediately to the provider.
- Resume strenuous aerobic exercise once mild cramping subsides.
Show the answer and explanation
Answer: B. Use a reliable barrier method of contraception for the next 6 to 12 months.
Topic: Hydatidiform mole contraception guidance
Following evacuation of a hydatidiform mole, reliable contraception (such as condoms or oral contraceptives) must be used for 6 to 12 months. This is crucial because rising or persistently elevated human chorionic gonadotropin (hCG) levels during surveillance can indicate gestational trophoblastic neoplasia, and a new pregnancy would confound hCG monitoring.
Why the others are wrong
- A – Pregnancy must be strictly avoided during the surveillance period because hCG levels from a new pregnancy would obscure potential malignant transformation.
- C – A decrease in bleeding is a normal finding; heavy bleeding, foul discharge, or rising hCG levels are the warning signs to report.
- D – Strenuous exercise should be restricted for several weeks to allow physical and uterine recovery.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
36Question
A nurse is assessing a newborn delivered at 39 weeks gestation to a mother with poorly controlled gestational diabetes mellitus. Which clinical findings should the nurse anticipate observing during the initial transition period?
Select all that apply.
- Macrosomia with excess adipose tissue deposition
- Polycythemia due to intrauterine hypoxia
- Hyperglycemia resulting from prolonged maternal glucose exposure
- Hypocalcemia secondary to functional hypoparathyroidism
- Respiratory distress syndrome due to delayed surfactant production
Show the answers and explanation
Answers: A, B, D and E.
- A – Macrosomia with excess adipose tissue deposition
- B – Polycythemia due to intrauterine hypoxia
- D – Hypocalcemia secondary to functional hypoparathyroidism
- E – Respiratory distress syndrome due to delayed surfactant production
Topic: Infant of diabetic mother complications
Infants of mothers with poorly controlled diabetes experience chronic intrauterine hyperinsulinemia, leading to macrosomia (A), polycythemia due to increased oxygen consumption and relative hypoxia (B), hypocalcemia from parathyroid suppression (D), and delayed surfactant synthesis causing respiratory distress syndrome (E). The infant experiences rapid hypoglycemia after birth, not hyperglycemia (C).
Why the others are wrong
- C – The newborn develops acute hypoglycemia after birth because maternal glucose is abruptly cut off while fetal hyperinsulinemia persists.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
37Question
A nurse is caring for a client at 12 weeks of gestation who is diagnosed with a complete hydatidiform mole. Which action should the nurse include in the client's immediate plan of care?
- Administer prophylactic oxytocin infusion to facilitate uterine evacuation.
- Prepare the client for suction curettage and monitor for hemorrhage.
- Schedule a repeat ultrasound in 4 weeks to monitor spontaneous resorption.
- Collect a 24-hour urine collection for estriol levels to assess fetal well-being.
Show the answer and explanation
Answer: B. Prepare the client for suction curettage and monitor for hemorrhage.
Topic: Hydatidiform mole management
A complete hydatidiform mole (gestational trophoblastic disease) requires prompt evacuation of the uterine contents, typically via suction curettage. Due to the high vascularity of molar tissue and enlarged uterus, the client is at significant risk for hemorrhage, requiring close post-evacuation monitoring and administration of uterotonics as prescribed.
Why the others are wrong
- A – Oxytocin is ineffective for evacuating a first-trimester molar pregnancy and can increase the risk of trophoblastic embolization.
- C – Molar pregnancies do not spontaneously resorb and require prompt evacuation to prevent malignant sequelae.
- D – There is no fetus present in a complete mole, and serial hCG levels—not 24-hour urine estriol—are required for monitoring.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
38Question
A nurse is caring for a client at 28 weeks of gestation who has gestational diabetes mellitus and receives instructions on managing blood glucose levels during illness ("sick-day rules"). Which statement by the client indicates a need for further teaching?
- -"I will check my blood glucose levels at least four times a day."
- -"I should test my urine for ketones if my blood glucose exceeds 200 mg/dL."
- -"I will stop taking my insulin if I am vomiting and unable to keep food down."
- -"I should drink plenty of sugar-free fluids to prevent dehydration while sick."
Show the answer and explanation
Answer: C. -"I will stop taking my insulin if I am vomiting and unable to keep food down."
Topic: Gestational diabetes sick-day management
Clients with diabetes must never stop taking insulin during acute illness or nausea/vomiting, even if oral intake is poor. Stress hormones released during illness elevate blood glucose levels, and omitting insulin places the client at high risk for diabetic ketoacidosis (DKA), which threatens both maternal and fetal well-being.
Why the others are wrong
- A – Checking blood glucose frequently during illness is correct because stress hormones cause erratic glycemic control.
- B – Testing for urinary ketones when blood glucose is elevated (>200 mg/dL) is correct to detect impending ketoacidosis early.
- D – Consuming adequate sugar-free fluids is correct to maintain hydration and prevent concentration of glucose.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
39Question
A nurse is assisting a provider who is performing an external cephalic version (ECV) for a client at 37 weeks of gestation with a breech presentation. Which of the following findings during or immediately after the procedure require immediate nursing intervention?
Select all that apply.
- Maternal blood pressure of 118/76 mm Hg
- Fetal heart rate baseline of 100 beats/min with minimal variability persisting for 10 minutes
- Client report of mild, dull abdominal discomfort during the maneuver
- Active vaginal bleeding saturating one perineal pad
- Fetal heart rate showing recurrent late decelerations following the procedure
Show the answers and explanation
Answers: B, D and E.
- B – Fetal heart rate baseline of 100 beats/min with minimal variability persisting for 10 minutes
- D – Active vaginal bleeding saturating one perineal pad
- E – Fetal heart rate showing recurrent late decelerations following the procedure
Topic: External cephalic version complications
Complications of external cephalic version include uteroplacental abruption, umbilical cord compression, and fetal distress. Persistent fetal bradycardia or minimal variability, active vaginal bleeding indicating placental separation, and recurrent late decelerations signaling uteroplacental insufficiency all require urgent intervention. Mild discomfort and normal vital signs are expected variants.
Why the others are wrong
- A – A normal maternal blood pressure reading is an expected, stable finding and requires no intervention.
- C – Mild, dull abdominal discomfort is a common and expected sensation during external manipulation of the fetus.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
40Question
A pregnant client at 34 weeks gestation with preeclampsia with severe features receives a continuous intravenous infusion of magnesium sulfate. Which assessment finding requires the nurse to immediately stop the infusion?
- Maternal respiratory rate of 10 breaths/min
- Serum magnesium level of 7.0 mg/dL
- Trace proteinuria on dipstick urinalysis
- Deep tendon reflexes rated as 2+
Show the answer and explanation
Answer: A. Maternal respiratory rate of 10 breaths/min
Topic: Magnesium sulfate safety assessment
A respiratory rate below 12 breaths/min indicates central nervous system depression from hypermagnesemia, which precedes respiratory arrest. The nurse must immediately stop the infusion and administer calcium gluconate as the antidote.
Why the others are wrong
- B – A serum magnesium level of 7.0 mg/dL is within the accepted therapeutic range (4 to 7 mg/dL) for seizure prophylaxis in preeclampsia.
- C – Trace proteinuria is a characteristic finding of preeclampsia and does not indicate acute magnesium toxicity.
- D – Deep tendon reflexes of 2+ are normal and expected; absent reflexes (0) would indicate magnesium toxicity.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
41Question
A postpartum client who delivered a term infant 2 hours ago expresses a sudden urge to defecate and reports severe, sharp perineal pain. Her fundus is firm and midline, and her lochia is moderate rubra. Vital signs are: blood pressure 98/62 mmHg, pulse 118/min, and respirations 22/min. Which action should the nurse take first?
- Administer the prescribed simethicone for gas pains.
- Inspect and palpate the perineal and vaginal areas.
- Assist the client to the bathroom to attempt a bowel movement.
- Increase the rate of the intravenous lactated Ringer's infusion.
Show the answer and explanation
Answer: B. Inspect and palpate the perineal and vaginal areas.
Topic: Postpartum perineal hematoma assessment
A sudden urge to defecate combined with severe perineal pain and signs of hypovolemia (tachycardia, hypotension) in a postpartum client with a firm fundus strongly indicates a concealed postpartum hemorrhage caused by a vaginal or perineal hematoma. The nurse must immediately inspect and palpate the perineum to assess for swelling, discoloration, and hematoma formation.
Why the others are wrong
- A – Administering simethicone assumes gas is the cause, ignoring the critical signs of hypovolemic shock and perineal pressure characteristic of a hematoma.
- C – Assisting the client to the bathroom or allowing her to strain can exacerbate bleeding and rupture an expanding hematoma.
- D – Increasing IV fluids is appropriate for hypovolemia, but identifying and addressing the underlying source of bleeding (the hematoma) through physical inspection is the essential first step.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
42Question
A 32-year-old primigravida at 34 weeks of gestation is admitted for evaluation of suspected severe gestational hypertension. Which clinical finding, if noted during the initial assessment, would differentiate severe gestational hypertension from mild gestational hypertension?
- Blood pressure of 152/98 mm Hg measured twice, 4 hours apart
- Serum creatinine level of 1.4 mg/dL
- Trace protein on a random urine dipstick test
- Client report of mild dependent ankle edema at the end of the day
Show the answer and explanation
Answer: B. Serum creatinine level of 1.4 mg/dL
Topic: Gestational hypertension severity criteria
Renal insufficiency, indicated by a serum creatinine greater than 1.1 mg/dL or a doubling of serum creatinine in the absence of other renal disease, is a defining feature of severe gestational hypertension/preeclampsia. Mild gestational hypertension involves a blood pressure of 140/90 mm Hg or higher without end-organ dysfunction.
Why the others are wrong
- A – A blood pressure of 152/98 mm Hg meets criteria for gestational hypertension but requires 160/110 mm Hg or higher for the blood pressure criterion of severe disease.
- C – Trace proteinuria on a dipstick is not diagnostic of severe features; significant proteinuria or specific end-organ damage is required.
- D – Mild dependent ankle edema is a common physiological finding in late pregnancy and is not an indicator of severe hypertension.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
43Question
A nurse is providing discharge instructions to a postpartum client who delivered a healthy term newborn 48 hours ago. Which statement by the client indicates a correct understanding of normal lochia progression?
- "My bleeding should stay bright red for at least the next 3 weeks."
- "It is normal for the discharge to change from pinkish-brown to yellowish-white over the next few weeks."
- "If I suddenly pass clots the size of a grapefruit, I should rest and recheck it tomorrow."
- "The bleeding will stop completely by the time I leave the hospital today."
Show the answer and explanation
Answer: B. "It is normal for the discharge to change from pinkish-brown to yellowish-white over the next few weeks."
Topic: Lochia stages and education
Normal lochia progresses predictably from lochia rubra (bright red, days 1-3), to lochia serosa (pinkish-brown, days 4-10), and finally to lochia alba (yellowish-white, up to 4-6 weeks postpartum). Option B accurately reflects the transition to serosa and alba.
Why the others are wrong
- A – Bright red lochia (rubra) typically only lasts for the first 3 days postpartum; prolonged bright red bleeding indicates a potential complication.
- C – Passing clots the size of a grapefruit is a major red flag for postpartum hemorrhage and requires immediate reporting, not delayed evaluation.
- D – Lochia does not stop at discharge; it continues for several weeks as the uterus involutes.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
44Question
A primigravida client at 38 weeks gestation is in the active phase of labor. The nurse notes late decelerations on the fetal monitor tracing with moderate variability. Which action should the nurse take first?
- Prepare the client for an emergency cesarean birth
- Administer oxygen at 10 L/min via non-rebreather mask
- Reposition the client to the lateral position
- Discontinue the oxytocin infusion immediately
Show the answer and explanation
Answer: C. Reposition the client to the lateral position
Topic: Late decelerations nursing management
Late decelerations indicate uteroplacental insufficiency. The priority nursing intervention is to improve placental blood flow and fetal oxygenation by changing the maternal position to a lateral (left or right) posture, which relieves compression on the inferior vena cava and aorta.
Why the others are wrong
- A – An emergency cesarean birth is premature before attempting conservative intrauterine resuscitation measures and evaluating fetal response.
- B – Oxygen administration is secondary and no longer routinely recommended unless maternal hypoxia is present, making repositioning the primary mechanical fix.
- D – Discontinuing oxytocin is correct if oxytocin is infusing, but repositioning is the immediate first physical maneuver to enhance placental perfusion.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
45Question
A nurse is providing discharge instructions to a postpartum client who is formula-feeding her newborn. Which statement by the client indicates a correct understanding of lactation suppression?
- «I will use a breast pump every 3 hours to relieve engorgement pain.»
- «I should apply warm compresses to my breasts for 20 minutes four times a day.»
- «I will wear a supportive, snug-fitting bra continuously for the next few days.»
- «I can express milk in the shower if my breasts feel overly full and heavy.»
Show the answer and explanation
Answer: C. «I will wear a supportive, snug-fitting bra continuously for the next few days.»
Topic: Lactation suppression client education
Wearing a supportive, snug-fitting bra continuously helps suppress lactation by minimizing breast tissue movement and supporting the breasts without stimulating milk production. Pumping, expressing milk, or applying heat all stimulate prolactin release and milk production, which worsens engorgement.
Why the others are wrong
- A – Using a breast pump stimulates milk production and delays lactation suppression.
- B – Warm compresses cause vasodilation and stimulate milk flow; cold compresses should be used instead for comfort.
- D – Expressing milk signals the body to produce more milk, counteracting the suppression process.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
46Question
A nurse is providing discharge education to a client who is 2 days postpartum following an uncomplicated vaginal birth and is formula-feeding. The client asks how to manage breast engorgement. Which non-pharmacological interventions should the nurse include in the teaching?
Select all that apply.
- Apply warm compresses to the breasts for 20 minutes prior to feeding.
- Wear a supportive, well-fitted bra continuously for the first few days.
- Apply crushed ice packs wrapped in a towel to the breasts for 15 to 20 minutes.
- Express small amounts of breast milk manually when pressure becomes unbearable.
- Apply raw cabbage leaves directly inside the bra to the breasts.
Show the answers and explanation
Answers: B, C, D and E.
- B – Wear a supportive, well-fitted bra continuously for the first few days.
- C – Apply crushed ice packs wrapped in a towel to the breasts for 15 to 20 minutes.
- D – Express small amounts of breast milk manually when pressure becomes unbearable.
- E – Apply raw cabbage leaves directly inside the bra to the breasts.
Topic: Engorgement management in non-breastfeeding clients
For non-breastfeeding clients experiencing engorgement, measures are aimed at reducing milk production and relieving discomfort without stimulating lactation. Wearing a firm, supportive bra, applying cold packs, placing raw cabbage leaves, and occasionally expressing just enough milk to relieve extreme pressure are effective strategies.
Why the others are wrong
- A – Warm compresses stimulate milk flow and vasodilation, which worsens engorgement in non-breastfeeding clients. Warmth is reserved for breastfeeding mothers just before nursing.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
47Question
A nurse is caring for a client at 32 weeks of gestation who is admitted for suspected preterm labor. The primary healthcare provider prescribes betamethasone 12 mg IM now. Which of the following is the primary physiological goal of administering this medication?
- To halt uterine contractions by relaxing smooth muscle fibers
- To accelerate fetal lung maturity and reduce the incidence of respiratory distress syndrome
- To decrease maternal blood pressure and prevent eclamptic seizures
- To prevent Group B Streptococcus neonatal sepsis during preterm delivery
Show the answer and explanation
Answer: B. To accelerate fetal lung maturity and reduce the incidence of respiratory distress syndrome
Topic: Antenatal corticosteroid therapy mechanism
Antenatal corticosteroids such as betamethasone are administered to pregnant women at risk of preterm birth to stimulate fetal surfactant production, thereby accelerating lung maturity and reducing neonatal morbidity and mortality associated with respiratory distress syndrome.
Why the others are wrong
- A – Betamethasone does not stop uterine contractions; tocolytics such as nifedipine or tocotriol-inhibitors serve that purpose.
- C – Blood pressure control and seizure prevention are managed with medications such as labetalol and magnesium sulfate, not corticosteroids.
- D – Antibiotics such as ampicillin or penicillin are used for intrapartum prophylaxis against Group B Streptococcus.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
48Question
A nurse in an antepartum clinic is assessing a client who is at 28 weeks of gestation. Which finding reported by the client requires immediate follow-up by the nurse?
- Mild dependent edema in both lower extremities at the end of the day
- Occasional painless tightening of the uterus that resolves with walking
- Intermittent throbbing headache unresponsive to acetaminophen and accompanied by blurred vision
- White, thick vaginal discharge with intense perineal pruritus
Show the answer and explanation
Answer: C. Intermittent throbbing headache unresponsive to acetaminophen and accompanied by blurred vision
Topic: Prenatal warning signs and preeclampsia symptoms
Persistent severe headaches accompanied by visual disturbances (such as blurred vision or scotomata) at 28 weeks gestation are classic warning signs of preeclampsia, which requires immediate evaluation to prevent severe maternal and fetal complications.
Why the others are wrong
- A – Mild dependent lower extremity edema is a normal hemodynamic finding in the third trimester due to increased venous pressure.
- B – Occasional painless contractions that resolve with rest or ambulation are characteristic of benign Braxton Hicks contractions.
- D – Vulvovaginal candidiasis causes thick discharge and itching, which is common during pregnancy and requires treatment but is not an immediate life-threatening emergency.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
49Question
A nurse is caring for a client who is 4 hours postpartum following a spontaneous vaginal birth. The client's vital signs are: blood pressure 112/70 mm Hg, heart rate 88/min, respiratory rate 18/min, and temperature 37.0°C (98.6°F). The nurse palpates the uterine fundus and notes that it is boggy, located 2 cm above the umbilicus, and displaced 3 cm to the right. Which of the following is the priority nursing action?
- Administer methylergonovine intramuscularly as prescribed.
- Assist the client to empty her bladder.
- Perform a straight catheterization immediately.
- Increase the rate of the intravenous oxytocin infusion.
Show the answer and explanation
Answer: B. Assist the client to empty her bladder.
Topic: Postpartum bladder distension and uterine atony
A boggy uterus displaced to the right is a classic sign of a distended bladder, which prevents the uterus from contracting effectively. Assisting the client to void is the primary, least invasive intervention to correct uterine atony caused by bladder distension.
Why the others are wrong
- A – Methylergonovine is a potent uterotonic used for postpartum hemorrhage due to uterine atony, but it is contraindicated in clients with hypertension and should not be used before resolving a simple bladder distension.
- C – While a straight catheterization may be necessary if the client cannot void, assisting the client to the bathroom to attempt a spontaneous void is the less invasive first choice.
- D – Increasing IV oxytocin may be indicated if massage and voiding fail to firm the uterus, but addressing the physical displacement caused by a full bladder takes precedence.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
50Question
A nurse is assessing a primigravida client at 34 weeks of gestation who was recently diagnosed with gestational hypertension. Which of the following findings should the nurse report immediately to the health care provider?
Select all that apply.
- Blood pressure of 148/92 mm Hg
- 3+ protein on urine dipstick
- Report of a continuous frontal headache
- Fetal heart rate baseline of 145/min with moderate variability
- Visual disturbances such as blurred vision or scotoma
Show the answers and explanation
Answers: B, C and E.
- B – 3+ protein on urine dipstick
- C – Report of a continuous frontal headache
- E – Visual disturbances such as blurred vision or scotoma
Topic: Gestational hypertension and preeclampsia transition
Gestational hypertension progressing to proteinuria, visual disturbances, or severe headache indicates transition to preeclampsia with severe features, which requires immediate medical intervention to prevent maternal stroke or eclamptic seizures.
Why the others are wrong
- A – A blood pressure of 148/92 mm Hg meets the criteria for gestational hypertension (systolic >= 140 or diastolic >= 90) but is not a sudden critical spike requiring immediate emergency provider notification compared to severe features.
- D – A fetal heart rate of 145/min with moderate variability is a normal, reassuring finding indicating a healthy fetal status.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
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Nursing