LPN Maternal and Neonatal Nursing 1 — Questions and Answers

Question 1: A client at 38 weeks gestation reports sudden, painless, bright red vaginal bleeding. The LPN should first:

Perform a vaginal examination to assess cervical dilation
Notify the charge nurse immediately and do NOT perform a vaginal exam (Correct answer)
Apply a pad count and reassess in 30 minutes
Prepare the client for an amniotomy

Correct answer: Notify the charge nurse immediately and do NOT perform a vaginal exam

Sudden painless bright red bleeding in the third trimester suggests placenta previa. Vaginal exams are contraindicated as they can cause massive hemorrhage. The charge nurse must be notified immediately.

Placenta previa occurs when the placenta partially or completely covers the cervical os. Painless, bright red vaginal bleeding in the third trimester is the classic presentation. Any vaginal examination can disrupt the placenta and trigger catastrophic hemorrhage. The LPN must: notify the charge nurse and provider immediately, do NOT perform a vaginal exam, maintain bed rest, apply external fetal monitoring, establish IV access, monitor vital signs and fetal heart rate, and prepare for possible emergency cesarean section. Diagnosis is confirmed by ultrasound.

Question 2: An Apgar score is assessed at 1 minute and 5 minutes after birth. Which Apgar score at 5 minutes indicates a neonate in good condition?

Score of 3
Score of 5
Score of 7–10 (Correct answer)
Score of 6

Correct answer: Score of 7–10

An Apgar score of 7–10 at 5 minutes indicates a neonate in good condition requiring only routine care. Scores below 7 indicate the need for intervention.

The Apgar score evaluates five criteria at 1 and 5 minutes of life: Appearance (skin color), Pulse, Grimace (reflex irritability), Activity (muscle tone), and Respiration. Each is scored 0–2, maximum 10. Score 7–10: good condition, routine care; 4–6: some compromise, supplemental oxygen, stimulation; 0–3: requires immediate resuscitation. The 5-minute score is more prognostically significant than the 1-minute score. A score that does not improve to 7 or above by 5 minutes warrants further assessment and resuscitation.

Question 3: A postpartum client 6 hours after vaginal delivery has a uterus that is boggy, displaced to the right, and 2 fingerbreadths above the umbilicus. The LPN's first action should be:

Massage the fundus vigorously
Have the client void, then reassess fundal height and tone (Correct answer)
Notify the charge nurse of postpartum hemorrhage
Apply ice to the abdomen to decrease bleeding

Correct answer: Have the client void, then reassess fundal height and tone

A displaced uterus suggests a full bladder displacing the uterus upward and to the side, preventing proper contraction. Voiding should occur before fundal massage.

The most common cause of a displaced, boggy uterus in the early postpartum period is bladder distension. A full bladder pushes the uterus up and to the right of midline and prevents it from contracting. The LPN should first assist the client to void or insert a catheter if unable to void spontaneously. After bladder emptying, reassess: the uterus should return to midline, firm up, and descend. If the uterus remains boggy after voiding, then fundal massage and notification of the charge nurse are appropriate. Premature vigorous massage without addressing the bladder is incorrect.

Question 4: The LPN is monitoring a laboring client and notes late decelerations on the fetal monitor. What is the appropriate intervention?

Increase the Pitocin infusion to speed delivery
Reposition the client to her left side, administer oxygen, and stop Pitocin (Correct answer)
Document the findings and continue monitoring
Perform a vaginal exam to assess progress

Correct answer: Reposition the client to her left side, administer oxygen, and stop Pitocin

Late decelerations indicate uteroplacental insufficiency. The nurse should reposition to left lateral, apply oxygen, stop Pitocin, and notify the charge nurse and provider immediately.

Late decelerations are gradual decreases in fetal heart rate that begin after the peak of a contraction and return to baseline after it ends, indicating uteroplacental insufficiency. Immediate interventions (LION): change position to Left lateral to improve placental perfusion by relieving aortic compression; Oxygen via non-rebreather mask at 8–10 L/min; IV fluids to improve maternal cardiac output; Notify charge nurse and provider; Stop Pitocin (oxytocin) to reduce uterine hyperstimulation. Late decelerations are ominous and may require emergency cesarean delivery.

Question 5: A breastfeeding client 2 days postpartum reports breast engorgement. The LPN should advise the client to:

Stop breastfeeding temporarily and apply ice packs
Feed frequently (every 1–2 hours), apply warm compresses before feeding, and cold packs after (Correct answer)
Apply cabbage leaves and reduce fluid intake
Switch to formula feeding to relieve engorgement

Correct answer: Feed frequently (every 1–2 hours), apply warm compresses before feeding, and cold packs after

Frequent feedings reduce milk accumulation, warm compresses before feeding promote let-down, and cold packs after feeding reduce inflammation and discomfort.

Breast engorgement peaks at 3–5 days postpartum as milk transitions from colostrum. Management: feed frequently every 1–3 hours to empty breasts; apply warm compresses or take a warm shower before feeding to stimulate let-down; massage the breast gently; hand express or pump to soften the areola if the baby cannot latch; apply cold packs (ice bags wrapped in cloth, or frozen cabbage leaves) after feeding to reduce swelling and discomfort. Stopping breastfeeding worsens engorgement and is counterproductive. Frequent, effective emptying is the primary treatment.

Question 6: A newborn's blood glucose is 38 mg/dL at 2 hours of age. The infant is jittery and feeding poorly. The priority intervention is:

Recheck glucose in 4 hours before taking action
Initiate early oral feeding with breast milk or formula and recheck glucose
Administer oral glucose gel per protocol and notify the provider (Correct answer)
Place the infant under a radiant warmer

Correct answer: Administer oral glucose gel per protocol and notify the provider

A blood glucose below 45 mg/dL in a symptomatic neonate requires treatment. Oral dextrose gel per protocol is the first-line treatment along with early feeding, and the provider must be notified.

Neonatal hypoglycemia is defined as blood glucose <45 mg/dL (some protocols use <40 mg/dL). Symptomatic hypoglycemia (jitteriness, tremors, poor feeding, lethargy, seizures) requires immediate treatment. Many NICUs use buccal dextrose gel (40% glucose gel, 0.5 mL/kg) as first-line treatment per AAP guidelines, followed by breastfeeding within 30 minutes and glucose recheck in 30 minutes. IV dextrose is required if oral treatment fails or if the infant is severely symptomatic. All symptomatic neonatal hypoglycemia requires provider notification.

Question 7: A client at 36 weeks gestation presents with a blood pressure of 158/104 mmHg, proteinuria (3+ on dipstick), and a severe frontal headache. The LPN should recognize this as:

Normal blood pressure elevation of late pregnancy
Gestational hypertension without protein
Severe preeclampsia requiring immediate escalation (Correct answer)
Preterm labor symptoms

Correct answer: Severe preeclampsia requiring immediate escalation

BP ≥160/110 mmHg with proteinuria and severe headache meets criteria for severe preeclampsia, a dangerous obstetric emergency requiring immediate intervention and possible delivery.

Preeclampsia is defined as hypertension (≥140/90 mmHg) plus proteinuria after 20 weeks gestation. Severe features include: BP ≥160/110 mmHg, severe headache, visual disturbances, right upper quadrant pain, thrombocytopenia, or impaired renal or liver function. This represents a medical emergency risking maternal stroke, seizures (eclampsia), HELLP syndrome, and fetal compromise. The LPN must notify the charge nurse and provider immediately, initiate seizure precautions (padded side rails, low lighting, quiet environment), and anticipate orders for IV magnesium sulfate and antihypertensives.

Question 8: A client receiving magnesium sulfate for preeclampsia has absent deep tendon reflexes (DTRs) and a respiratory rate of 12 breaths/minute. The LPN should immediately:

Increase the magnesium infusion rate to maintain therapeutic levels
Stop the magnesium infusion and administer calcium gluconate IV (Correct answer)
Reposition the client and continue monitoring DTRs every hour
Document the findings as expected side effects

Correct answer: Stop the magnesium infusion and administer calcium gluconate IV

Absent DTRs and respiratory rate of 12 are signs of magnesium toxicity. The infusion must be stopped immediately and calcium gluconate (the antidote) administered.

Magnesium sulfate toxicity progresses: loss of DTRs (first sign, occurs at serum Mg 7–10 mEq/L) → respiratory depression (>10 mEq/L) → cardiac arrest (>15 mEq/L). The LPN must monitor: DTRs hourly (hold if absent), respiratory rate every 15 minutes (hold if <12/min), urine output (≥25–30 mL/hr), and level of consciousness. When toxicity is identified: STOP the infusion immediately, administer calcium gluconate 1 g IV slowly over 3 minutes (antidote), apply supplemental oxygen, notify the charge nurse and provider, and prepare for possible respiratory support.

Question 9: A client 12 hours postpartum is assessed and has a temperature of 38.9°C (102°F). The LPN should first:

Encourage fluid intake to reduce fever caused by dehydration
Administer the prescribed acetaminophen and document the finding
Notify the charge nurse — a fever this high this early may indicate infection (Correct answer)
Apply ice packs to reduce fever before notifying anyone

Correct answer: Notify the charge nurse — a fever this high this early may indicate infection

A temperature of 38.9°C (102°F) within 24 hours of delivery (beyond the first 24-hour physiologic rise) is abnormal and may indicate endometritis, UTI, or wound infection requiring prompt evaluation.

A low-grade temperature (≤38°C/100.4°F) in the first 24 hours postpartum may be related to dehydration, engorgement, or a physiologic stress response. However, a temperature of 38.9°C (102°F) after the first 24 hours is suggestive of postpartum infection (puerperal morbidity is defined as ≥38°C on 2 days after the first 24 hours). Common sources: endometritis (most common post-cesarean), UTI, wound infection, mastitis, thrombophlebitis. The LPN should notify the charge nurse and anticipate a workup including CBC, urinalysis, culture, and possible IV antibiotics.

Question 10: When performing a newborn assessment, the LPN notes the following: acrocyanosis of hands and feet, heart rate 138 bpm, and respiratory rate 44 breaths/minute. The appropriate action is:

Initiate resuscitation — these findings indicate cardiorespiratory compromise
Administer supplemental oxygen for the cyanosis
Document findings as normal for a newborn (Correct answer)
Notify the NICU immediately

Correct answer: Document findings as normal for a newborn

Acrocyanosis (blue hands and feet) is normal in the first 24–48 hours of life. Heart rate 120–160 bpm and respiratory rate 30–60 breaths/minute are normal for neonates.

Normal newborn vital sign ranges: heart rate 120–160 bpm, respiratory rate 30–60 breaths/minute, temperature 36.5–37.5°C, blood pressure ~65/40 mmHg. Acrocyanosis (peripheral cyanosis of the hands and feet) is a normal finding in the first 24–48 hours as the peripheral circulation adjusts to extrauterine life. Central cyanosis (blueness of the lips, tongue, or trunk) is abnormal and requires immediate intervention. All assessed values in this question are within normal limits. The LPN should document and continue routine newborn care.

Question 11: A nurse is assessing a newborn and notes a soft mass on the back of the skull that crosses the suture line. This finding is consistent with:

Caput succedaneum (Correct answer)
Cephalohematoma
Craniosynostosis
Normal molding

Correct answer: Caput succedaneum

Caput succedaneum is soft tissue edema of the scalp that crosses suture lines, present at birth, and resolves within days. Cephalohematoma is subperiosteal bleeding that does NOT cross suture lines.

Caput succedaneum is diffuse, pitting edema of the scalp from pressure during labor and delivery. Key features: present at birth, crosses suture lines, and resolves within 1–3 days. Cephalohematoma is a collection of blood between the periosteum and the skull bone; it is firm, does NOT cross suture lines (respects periosteal boundaries), appears within hours of birth, and resolves in weeks to months. Cephalohematoma raises bilirubin risk as the blood breaks down. Both require education and reassurance, but cephalohematoma requires monitoring for jaundice.

Question 12: A postpartum client who is Rh-negative delivered an Rh-positive baby. The LPN knows that Rho(D) immune globulin (RhoGAM) must be administered:

Within 72 hours of delivery (Correct answer)
Within 24 hours of delivery
7–10 days postpartum at the first outpatient visit
Only if the client has a positive indirect Coombs test

Correct answer: Within 72 hours of delivery

RhoGAM must be given within 72 hours of delivery to prevent Rh sensitization in the Rh-negative mother, protecting future pregnancies from hemolytic disease of the newborn.

Rh incompatibility occurs when an Rh-negative mother carries an Rh-positive fetus. Fetal blood can enter the maternal circulation during delivery, causing the mother to produce anti-D antibodies that attack future Rh-positive fetuses (hemolytic disease of the newborn). RhoGAM (Rho(D) immune globulin) suppresses this immune response if given within 72 hours of delivery. It is also given at 28 weeks gestation prophylactically, and after any sensitizing event (miscarriage, amniocentesis, trauma). RhoGAM is NOT given if the mother has already developed antibodies (positive indirect Coombs test = already sensitized).

Question 13: A client is in active labor and suddenly reports a tearing sensation followed by cessation of contractions and severe abdominal pain. The fetal heart rate shows severe variable decelerations. The LPN recognizes this as:

Normal transition from active to transition phase of labor
Placental abruption
Uterine rupture — a life-threatening emergency (Correct answer)
Cord prolapse

Correct answer: Uterine rupture — a life-threatening emergency

Uterine rupture presents with sudden severe abdominal pain, cessation of contractions, and fetal distress. This is a life-threatening obstetric emergency requiring emergency cesarean delivery.

Uterine rupture is a catastrophic obstetric emergency, most common in clients with a prior uterine scar (previous cesarean). Classic signs: sudden severe abdominal pain with a 'popping' or tearing sensation, abrupt cessation of contractions, loss of fetal station, fetal distress (severe bradycardia or absent FHR), maternal hypotension and shock from hemorrhage, and a visible change in uterine contour. The LPN must immediately call for help, stay with the client, apply oxygen, increase IV fluids, and prepare for emergency cesarean. Maternal and fetal mortality are high without immediate surgical intervention.

Question 14: A newborn's bilirubin level is 14 mg/dL at 36 hours of age. The LPN knows that phototherapy works by:

Stimulating the liver to conjugate bilirubin faster
Converting unconjugated bilirubin to water-soluble photoproducts excreted in bile and urine (Correct answer)
Reducing red blood cell breakdown through UV light exposure
Increasing gut motility to excrete bilirubin through stool faster

Correct answer: Converting unconjugated bilirubin to water-soluble photoproducts excreted in bile and urine

Phototherapy converts fat-soluble unconjugated bilirubin to water-soluble isomers (lumirubin and photobilirubin) that can be excreted in bile and urine without hepatic conjugation.

Unconjugated (indirect) bilirubin is lipid-soluble and cannot be excreted in urine. Phototherapy using blue-green light (wavelength 460–490 nm) converts bilirubin through two processes: isomerization to lumirubin (excreted in bile) and photooxidation to water-soluble products excreted in urine. The infant's eyes must be shielded during phototherapy to prevent retinal damage. The infant should be maximally exposed (undress except for diaper) and turned frequently. Frequent feedings promote bilirubin excretion through the gut. Temperature monitoring is essential as phototherapy increases insensible water loss.

Question 15: A client at 40 weeks gestation is being evaluated for prolonged labor. She has been in active labor for 18 hours without delivery and an oxytocin infusion is running. The fetal heart rate suddenly drops to 60 bpm for 30 seconds. The LPN's FIRST action is to:

Increase the oxytocin infusion to speed delivery
Turn the Pitocin off and call the charge nurse (Correct answer)
Apply fundal pressure to expedite delivery
Perform an internal vaginal exam to check for cord prolapse

Correct answer: Turn the Pitocin off and call the charge nurse

A prolonged fetal bradycardia (60 bpm for 30 seconds) while receiving oxytocin indicates uterine hyperstimulation or cord compromise. The first action is to stop the Pitocin and call the charge nurse.

Prolonged fetal bradycardia (FHR <100 bpm lasting >2 minutes) during oxytocin infusion suggests uterine tachysystole (>5 contractions in 10 minutes) causing placental compression, or cord prolapse. The LPN should: (1) Stop the oxytocin infusion immediately; (2) Change maternal position to left lateral or knee-chest (to relieve cord compression); (3) Apply 100% oxygen; (4) Increase IV fluids; (5) Notify the charge nurse and provider immediately. If cord prolapse is suspected, maintain manual elevation of the presenting part while awaiting emergency delivery.

Question 16: A postpartum client reports bilateral leg cramping but no unilateral leg swelling. The LPN's assessment reveals no warmth or redness in either leg. This finding is most likely:

Deep vein thrombosis requiring anticoagulation
Normal postpartum muscle cramping related to fatigue and fluid shifts (Correct answer)
Peripheral arterial disease exacerbated by pregnancy
Restless legs syndrome requiring neurological evaluation

Correct answer: Normal postpartum muscle cramping related to fatigue and fluid shifts

Bilateral leg cramping without swelling, redness, warmth, or tenderness is typically normal postpartum discomfort from fatigue, fluid redistribution, and muscle strain from labor.

After delivery, clients frequently experience bilateral leg cramping, aching, and swelling from fluid redistribution, blood volume changes, and muscular exhaustion from labor. These are bilateral, diffuse, and not associated with the classic DVT signs (unilateral calf tenderness, warmth, redness, edema, positive Homans' sign). DVT is a significant postpartum risk due to hypercoagulability, venous stasis, and immobility. The LPN should compare bilateral leg assessments, encourage ambulation, adequate hydration, and leg elevation. Any unilateral calf symptoms should be evaluated urgently.

Question 17: When caring for a client with a suspected ectopic pregnancy presenting with sharp right lower quadrant pain, vaginal spotting, and a positive pregnancy test, the LPN's priority is:

Prepare the client for a pelvic exam in the LPN's scope of practice
Monitor vital signs closely and report signs of shock to the charge nurse (Correct answer)
Schedule an outpatient ultrasound for the following week
Administer oral analgesics and discharge with follow-up instructions

Correct answer: Monitor vital signs closely and report signs of shock to the charge nurse

Ruptured ectopic pregnancy can cause life-threatening intraabdominal hemorrhage and hypovolemic shock. The LPN must monitor vital signs and report deterioration immediately.

Ectopic pregnancy (most common in the fallopian tube) can rupture, causing massive intraperitoneal hemorrhage and hypovolemic shock. Classic presentation: lower abdominal pain, vaginal bleeding, positive pregnancy test, with no intrauterine pregnancy on ultrasound. Risk factors: PID, prior ectopic, IUD use. The LPN should: monitor vital signs and SpO2 closely, establish IV access, be prepared for fluid resuscitation, report any deterioration (tachycardia, hypotension, diaphoresis, syncope) immediately, and anticipate emergency surgical intervention. Pelvic exams and surgical decision-making are outside LPN scope.

Question 18: A breastfed newborn has lost 10% of birth weight by day 3 of life. The LPN should:

Reassure the parents — this is within the normal 7–10% range so nothing is needed
Document the weight loss and report to the charge nurse or pediatric provider (Correct answer)
Immediately supplement with formula and discontinue breastfeeding
Start IV dextrose for suspected hypoglycemia

Correct answer: Document the weight loss and report to the charge nurse or pediatric provider

Weight loss of up to 7–10% in the first few days is normal, but 10% is at the upper limit and warrants assessment of breastfeeding effectiveness and reporting to the provider.

Newborns normally lose up to 7–10% of birth weight in the first 3–5 days of life due to meconium and urine passage plus fluid shifts. Weight should return to birth weight by 10–14 days. A 10% loss is at the upper acceptable limit and warrants concern, particularly in breastfed infants. The LPN should notify the charge nurse and provider, assess breastfeeding frequency (8–12 times/24 hours) and effectiveness, evaluate for adequate latch, number of wet/soiled diapers, and consider a lactation consultant. Supplementation may be recommended but the decision is made by the provider, not the LPN independently.

Question 19: A client in the second stage of labor begins pushing. The fetal presenting part is at +3 station. The LPN recognizes that:

The fetus is still in the upper pelvis and delivery is not imminent
The fetal head is 3 cm above the ischial spines
Delivery is imminent — the presenting part is 3 cm below the ischial spines (Correct answer)
An emergency cesarean will be needed

Correct answer: Delivery is imminent — the presenting part is 3 cm below the ischial spines

+3 station means the fetal presenting part is 3 cm below the ischial spines, very close to the perineum, indicating imminent delivery.

Station describes the relationship of the fetal presenting part to the ischial spines (0 station). Negative stations (-1 to -5) indicate the presenting part is above the ischial spines (not yet engaged). Zero station = engaged at the spines. Positive stations (+1 to +5) indicate the presenting part is below the spines. At +5, the presenting part is visible at the perineum (crowning). At +3, delivery is imminent. The LPN should not leave the client, ensure delivery equipment is ready, alert the charge nurse and provider, and prepare for delivery. The room should be set up for immediate birth.

Question 20: A client who delivered 2 days ago develops a temperature of 38.5°C (101.3°F), chills, and unilateral breast tenderness with redness and warmth. The LPN suspects:

Normal engorgement of early lactation
Mastitis and should report findings to the charge nurse (Correct answer)
Systemic sepsis requiring blood cultures immediately
Breast abscess requiring surgical drainage

Correct answer: Mastitis and should report findings to the charge nurse

Unilateral breast redness, warmth, tenderness, and fever are classic signs of mastitis — a breast infection most common in breastfeeding women requiring antibiotic treatment.

Mastitis is an inflammatory infection of the breast tissue, most common in the second week postpartum in breastfeeding women. Classic signs: unilateral redness, warmth, tenderness, and swelling of a segment of the breast, flu-like symptoms (fever >38.5°C, chills, myalgia), and malaise. Most commonly caused by Staphylococcus aureus from infant's oral flora through cracked nipples. Treatment: continue breastfeeding from the affected breast (prevents abscess), antibiotics (dicloxacillin or cephalexin), analgesics, warm compresses, and rest. The LPN should report findings to facilitate prompt antibiotic prescribing.

Question 21: A newborn is born at 32 weeks gestation and requires admission to the NICU. Which nursing action is the most important to support parental bonding?

Limit parental visitation to designated hours to prevent infection risk
Encourage skin-to-skin (kangaroo) care as soon as medically stable (Correct answer)
Discourage parents from touching the infant until the infant is stable
Maintain parents outside the NICU during procedures

Correct answer: Encourage skin-to-skin (kangaroo) care as soon as medically stable

Skin-to-skin (kangaroo) care promotes bonding, stabilizes neonatal temperature, heart rate, and oxygenation, and supports breastfeeding and parental confidence.

Kangaroo care (skin-to-skin contact) involves placing the naked infant on the parent's bare chest. Evidence-based benefits include: improved thermoregulation, stabilized heart rate and oxygen saturation, enhanced weight gain, reduced pain perception, improved breastfeeding rates, and strengthened parent-infant bonding. It can begin as soon as the preterm infant is medically stable, even with monitors attached. Family-integrated care in the NICU is standard of practice. Parents should be encouraged to participate in care, read to the infant, and hold the infant as much as possible.

Question 22: A client at 28 weeks gestation with preterm labor is prescribed betamethasone. The LPN understands this medication is given to:

Stop uterine contractions and prolong pregnancy
Accelerate fetal lung maturity by stimulating surfactant production (Correct answer)
Prevent Group B Streptococcus infection in the neonate
Reduce maternal blood pressure and prevent preeclampsia

Correct answer: Accelerate fetal lung maturity by stimulating surfactant production

Betamethasone is a corticosteroid given to the mother to stimulate surfactant production in the fetal lungs, reducing the severity of respiratory distress syndrome (RDS) if preterm birth occurs.

Betamethasone (or dexamethasone) is given IM to the pregnant woman threatened by preterm delivery between 24–34 weeks gestation. It crosses the placenta and stimulates the type II pneumocytes in fetal lungs to produce surfactant, which reduces surface tension in alveoli and prevents their collapse. A full course (2 doses 24 hours apart) significantly reduces the incidence and severity of neonatal respiratory distress syndrome (RDS), intraventricular hemorrhage, and necrotizing enterocolitis. Tocolytics stop contractions; GBS prophylaxis uses IV penicillin.

Question 23: The LPN is teaching a postpartum client about signs of postpartum depression (PPD). Which symptom most distinguishes PPD from the 'baby blues'?

Tearfulness and emotional lability in the first week
Mild anxiety about newborn care
Persistent symptoms beyond 2 weeks with inability to function or care for the infant (Correct answer)
Brief episodes of sadness that resolve with reassurance

Correct answer: Persistent symptoms beyond 2 weeks with inability to function or care for the infant

Baby blues resolve within 1–2 weeks. PPD involves persistent, debilitating symptoms beyond 2 weeks that impair the mother's ability to function and care for her infant.

Postpartum blues (affecting 50–80% of new mothers) involve mild, transient mood changes (tearfulness, anxiety, mood swings) beginning 3–5 days postpartum and resolving by 2 weeks. Postpartum depression (PPD) affects 10–20% of mothers and is characterized by: persistent symptoms >2 weeks, inability to function or care for self/infant, depressed mood, anhedonia, sleep/appetite disturbance, excessive guilt, and thoughts of harming self or infant. The Edinburgh Postnatal Depression Scale (EPDS) is a validated screening tool. PPD requires professional evaluation and may need therapy and/or medication. All new mothers should be screened.

Question 24: A newborn is born with meconium-stained amniotic fluid. The infant is vigorous at birth (crying, good tone, HR >100 bpm). The most appropriate action is:

Immediately intubate for tracheal suctioning before any stimulation
Dry, stimulate, and provide routine newborn care without tracheal suctioning (Correct answer)
Administer prophylactic antibiotics and observe in the NICU
Delay all care until meconium is cleared by suctioning the trachea

Correct answer: Dry, stimulate, and provide routine newborn care without tracheal suctioning

Per current NRP guidelines, routine tracheal suctioning for meconium is NOT recommended for vigorous infants. Routine care (drying and stimulation) is appropriate.

Per the updated 2020 American Academy of Pediatrics Neonatal Resuscitation Program (NRP) guidelines, routine intrapartum suctioning and routine tracheal suctioning for meconium-stained amniotic fluid is no longer recommended even for vigorous infants, as it has not been shown to reduce meconium aspiration syndrome and may cause harm. For vigorous infants (good cry, tone, HR >100 bpm), proceed with routine newborn care: dry, stimulate, place under radiant warmer. If the infant is NOT vigorous (depressed respirations, decreased tone, HR <100 bpm), consider laryngoscopy and possible suctioning under direct visualization.

Question 25: A pregnant client at 20 weeks gestation is scheduled for an amniocentesis. Which nursing action is most important after the procedure?

Encourage increased oral fluid intake for the next week
Monitor for uterine contractions, leaking fluid, and report decreased fetal movement (Correct answer)
Keep the client in supine position for 8 hours post-procedure
Perform a sterile vaginal examination to assess cervical dilation

Correct answer: Monitor for uterine contractions, leaking fluid, and report decreased fetal movement

Post-amniocentesis complications include preterm labor and membrane rupture. The client must be taught to monitor for contractions, fluid leaking from the vagina, fever, and decreased fetal movement.

Amniocentesis involves inserting a needle through the abdomen into the amniotic sac to withdraw fluid for genetic testing. Complications (occur in <0.5% of procedures) include: preterm labor, amniotic fluid leakage (membrane rupture), infection (chorioamnionitis), fetal injury, and fetal loss. Post-procedure nursing care: monitor for regular uterine contractions (preterm labor), report watery vaginal discharge (membrane rupture), monitor fetal heart tones, instruct client to avoid strenuous activity for 24 hours, report fever, abdominal pain, or decreased fetal movement. Most clients may resume normal activity within 24 hours.

Question 26: A client in active labor at 8 cm dilation requests an epidural. Which assessment is most important before the epidural is placed?

Client's pain tolerance level and birth plan preferences
Platelet count, blood pressure, and fluid status (Correct answer)
Whether the client has eaten within the last 4 hours
Fetal presentation and station

Correct answer: Platelet count, blood pressure, and fluid status

Before epidural placement, thrombocytopenia (risk of epidural hematoma), hypotension (worsened by sympathetic blockade), and adequate IV hydration are critical safety assessments.

Epidural anesthesia requires the following pre-procedure assessments: platelet count (thrombocytopenia <80,000/mm³ is a contraindication due to epidural hematoma risk); blood pressure baseline (epidurals cause sympathetic blockade and vasodilation leading to hypotension); IV fluid bolus (500–1,000 mL often given pre-epidural to prevent hypotension); coagulation status; and assessment for infection at the insertion site. IV access must be established before the epidural. Continuous fetal monitoring and blood pressure assessment every 5 minutes for 30 minutes post-placement are standard post-epidural care.

Question 27: A client at 10 weeks gestation reports spotting and mild cramping. A threatened abortion is suspected. The LPN's most appropriate response is:

Instruct the client to go home and rest in bed for 2 weeks
Notify the charge nurse and prepare the client for assessment and possible ultrasound (Correct answer)
Advise the client that spotting is normal in early pregnancy
Prepare the client for immediate dilation and curettage (D&C)

Correct answer: Notify the charge nurse and prepare the client for assessment and possible ultrasound

Any vaginal bleeding in early pregnancy requires immediate notification of the charge nurse and clinical assessment to determine fetal viability and rule out ectopic pregnancy or inevitable abortion.

Threatened abortion is defined as vaginal bleeding before 20 weeks with a closed cervical os and viable fetus. The LPN must notify the charge nurse and prepare the client for: pelvic exam by the RN/provider to assess os dilation, transvaginal ultrasound to confirm fetal heartbeat and intrauterine location, quantitative hCG levels, and blood type/Rh factor (RhoGAM if Rh-negative). Bed rest has not been proven to prevent miscarriage. D&C is performed for inevitable, incomplete, or missed abortion. Reassuring bleeding as normal without assessment is unsafe. Approximately 50% of threatened abortions progress to complete miscarriage.

Question 28: A nurse is assessing a laboring client and finds the umbilical cord visible at the vaginal introitus. The LPN's immediate action is:

Apply downward pressure on the fundus to push the presenting part onto the cord
Place a gloved hand in the vagina to elevate the presenting part off the cord and call for emergency help (Correct answer)
Reposition the client to supine and transport to the operating room
Administer oxygen and increase the IV rate while waiting for the provider

Correct answer: Place a gloved hand in the vagina to elevate the presenting part off the cord and call for emergency help

Cord prolapse is a life-threatening emergency. The LPN must manually elevate the presenting part off the cord to relieve compression and maintain this until emergency cesarean delivery.

Umbilical cord prolapse is an obstetric emergency — the cord prolapses ahead of or alongside the presenting part, causing cord compression between the baby and pelvis with each contraction, leading to fetal hypoxia. Immediate management: (1) Manually elevate the presenting part off the cord using a gloved hand inserted vaginally — maintain this until delivery; (2) Call for emergency help immediately; (3) Position the client in knee-chest or Trendelenburg position; (4) Apply moist saline gauze over an exposed cord (do NOT push it back in); (5) Administer 100% oxygen; (6) Continuous fetal monitoring; (7) Prepare for emergency cesarean. The LPN does not leave the client or remove the hand until delivery.

Question 29: A newborn has Apgar scores of 5 at 1 minute and 7 at 5 minutes. Based on these findings, the LPN should expect:

Emergency intubation and resuscitation
Routine newborn care — both scores indicate a normal healthy infant
Some initial intervention at birth followed by continued monitoring as the infant improves (Correct answer)
Immediate transfer to the NICU for respiratory support

Correct answer: Some initial intervention at birth followed by continued monitoring as the infant improves

An Apgar of 5 at 1 minute indicates some compromise requiring intervention; improvement to 7 at 5 minutes shows response to resuscitation measures. Continued monitoring is appropriate.

Apgar scoring interpretation: 7–10 = good condition, routine care; 4–6 = some compromise, stimulation and oxygen needed; 0–3 = severe compromise, full resuscitation. This infant scored 5 at 1 minute (some compromise requiring stimulation and/or oxygen), then improved to 7 at 5 minutes, indicating a positive response to resuscitative measures. This trajectory is reassuring but warrants continued close monitoring (reassessment every 5 minutes up to 20 minutes if scores remain <7). The infant does not meet criteria for NICU transfer based on these scores alone, but documentation, parental communication, and continuous assessment are priorities.

Question 30: A postpartum client has lochia rubra on day 6 after delivery with a saturated perineal pad in 1 hour. The LPN should:

Reassure the client that lochia rubra for 6 days is completely normal
Notify the charge nurse — lochia rubra beyond day 3–4 with heavy saturation may indicate postpartum hemorrhage (Correct answer)
Instruct the client to change pads more frequently
Advise the client to increase activity to help the uterus contract

Correct answer: Notify the charge nurse — lochia rubra beyond day 3–4 with heavy saturation may indicate postpartum hemorrhage

Lochia typically transitions from rubra (red) to serosa (pink-brown) by day 3–4. Persistent heavy red lochia on day 6 may indicate subinvolution or hemorrhage requiring evaluation.

Normal lochia progression: lochia rubra (bright red) days 1–3; lochia serosa (pink-brown) days 4–10; lochia alba (white/yellow) weeks 2–6. Saturating a pad in less than 1 hour (especially with clots >1 inch diameter or persistent rubra beyond day 4) is abnormal and suggests possible: subinvolution of the uterus (failure of the uterus to return to normal size), retained placental fragments, endometritis, or late postpartum hemorrhage (PPH occurring after 24 hours). The LPN must notify the charge nurse and provider, assess fundal height and tone, vital signs, and pad count. Late PPH is a potentially life-threatening complication.

Question 31: A nurse is caring for a newborn born to a hepatitis B surface antigen (HBsAg) positive mother. Which intervention is the priority within 12 hours of birth?

Isolate the newborn in a private room to prevent infection spread
Administer hepatitis B immunoglobulin (HBIG) and hepatitis B vaccine within 12 hours (Correct answer)
Obtain hepatitis B serology from the newborn to determine if infected
Delay all vaccines until the newborn is discharged to confirm health

Correct answer: Administer hepatitis B immunoglobulin (HBIG) and hepatitis B vaccine within 12 hours

Newborns of HBsAg-positive mothers must receive both HBIG and hepatitis B vaccine within 12 hours of birth to prevent perinatal hepatitis B transmission.

Perinatal hepatitis B transmission occurs in 70–90% of infants born to HBsAg-positive mothers without prophylaxis. Passive-active immunoprophylaxis: hepatitis B immunoglobulin (HBIG 0.5 mL IM) provides immediate passive immunity while the hepatitis B vaccine series initiates active immunity. Both must be given within 12 hours of birth, at separate injection sites. Efficacy is >90% when given within 12 hours. If HBIG is not given within 12 hours, the benefit decreases significantly. The newborn should complete the 3-dose hepatitis B vaccine series (birth, 1–2 months, 6 months). Testing for hepatitis B surface antigen and antibody should be done at 9–12 months to confirm vaccine response.

Question 32: A client at 32 weeks gestation develops severe epigastric pain, nausea, and right upper quadrant tenderness. Lab results show elevated liver enzymes (AST 280 U/L), thrombocytopenia (platelets 85,000/mm³), and microangiopathic hemolytic anemia. The LPN recognizes this as:

Acute appendicitis requiring emergency surgery
Cholecystitis from pregnancy-related gallstone formation
HELLP syndrome — a severe complication of preeclampsia requiring immediate escalation (Correct answer)
Normal abdominal discomfort of the third trimester

Correct answer: HELLP syndrome — a severe complication of preeclampsia requiring immediate escalation

HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is a severe, life-threatening variant of preeclampsia requiring immediate delivery regardless of gestational age.

HELLP syndrome is a life-threatening obstetric emergency characterized by: Hemolysis (microangiopathic hemolytic anemia — schistocytes on smear, elevated LDH, low haptoglobin), Elevated Liver enzymes (AST/ALT >70 U/L), and Low Platelets (<100,000/mm³). Symptoms: right upper quadrant/epigastric pain (liver distension), nausea, headache, malaise. Complications: hepatic rupture, DIC, acute kidney injury, placental abruption, pulmonary edema. The LPN must notify the charge nurse immediately, initiate seizure precautions, establish IV access, prepare for magnesium sulfate, and anticipate emergency delivery — the only definitive treatment regardless of gestational age.

Question 33: A client delivers a baby with a large neural tube defect (open meningomyelocele). Before surgical repair, the nurse's priority is to:

Place the infant prone and cover the defect with a dry sterile gauze
Place the infant in a lateral or prone position with moist sterile saline dressing over the defect and prevent rupture (Correct answer)
Apply petroleum jelly gauze and wrap tightly with elastic bandage
Position the infant supine with the defect exposed to air to prevent infection

Correct answer: Place the infant in a lateral or prone position with moist sterile saline dressing over the defect and prevent rupture

Before surgical closure, the open myelomeningocele must be covered with moist, sterile, non-adherent dressing to prevent drying, infection, and trauma to exposed neural tissue.

Open myelomeningocele (spina bifida with exposed neural tissue) requires immediate protective care: (1) Position the infant prone or in a lateral position to avoid pressure on the defect; (2) Cover with sterile saline-soaked gauze wrapped in a non-adherent covering to prevent drying, trauma, and bacterial contamination; (3) Maintain warmth (radiant warmer with care not to dry the dressing); (4) Do not apply petroleum-based products directly on neural tissue; (5) Establish IV access for antibiotics; (6) Monitor for hydrocephalus (head circumference, fontanelle fullness); (7) Emotional support for parents. Surgical closure is performed within 24–72 hours. Dry exposure increases infection and neural damage risk.

Question 34: A 3-hour-old neonate has a blood glucose of 40 mg/dL and appears lethargic with poor suck. After applying buccal glucose gel, the LPN should reassess blood glucose within:

4 hours — early morning fasting glucose level is more accurate
30–60 minutes to evaluate the response to treatment (Correct answer)
2 hours — standard reassessment interval for neonatal labs
24 hours — glucose stabilizes within a day of birth

Correct answer: 30–60 minutes to evaluate the response to treatment

After treating neonatal hypoglycemia with glucose gel or feeding, blood glucose should be rechecked within 30–60 minutes to determine if treatment was effective and glucose has normalized.

Neonatal hypoglycemia treatment protocols specify reassessment timelines based on gestational age, birth weight, and clinical risk. After administering buccal dextrose gel (40% concentration, 0.5 mL/kg) followed by breastfeeding or formula: recheck capillary glucose within 30–60 minutes to confirm adequate response. If glucose remains <45 mg/dL after gel and feeding, IV dextrose may be required. At-risk neonates (LGA, SGA, preterm, IDM) require glucose screening per protocol. Repeat glucose checks are done before subsequent feedings (every 2–3 hours) until glucose is stable for 12–24 hours. Four-hour intervals are too long for a symptomatic hypoglycemic neonate.

Question 35: A client in active labor has an epidural and her blood pressure drops from 122/78 to 88/52 mmHg. The fetal heart rate shows late decelerations. The LPN's priority intervention is to:

Stop the epidural infusion and wait for the blood pressure to stabilize
Administer IV ephedrine per protocol, turn to left lateral position, increase IV fluids, and apply oxygen (Correct answer)
Increase the epidural anesthetic rate to reduce maternal pain from hypotension
Lay the client flat and elevate her legs 90 degrees

Correct answer: Administer IV ephedrine per protocol, turn to left lateral position, increase IV fluids, and apply oxygen

Epidural-induced hypotension reduces uteroplacental perfusion (causing fetal late decelerations). Immediate treatment: left lateral position, IV fluids, oxygen, and ephedrine if BP remains low.

Epidural anesthesia blocks sympathetic nerve fibers, causing vasodilation and decreased venous return, leading to maternal hypotension. Hypotension reduces uteroplacental blood flow, causing fetal hypoxia (late decelerations). Treatment protocol: (1) Reposition to left lateral (relieve aortocaval compression by gravid uterus); (2) Increase IV fluid rate; (3) Apply 100% oxygen by non-rebreather mask; (4) Administer ephedrine 5–10 mg IV push (vasopressor of choice in obstetrics — less effect on uterine blood flow than pure alpha agonists); (5) Notify charge nurse and anesthesiologist; (6) Continuous fetal monitoring. Response should occur within 2–3 minutes. If fetal bradycardia persists, prepare for emergency delivery.

Question 36: A client at 28 weeks gestation with rupture of membranes (PROM) is admitted. Fetal heart rate is 160 bpm with moderate variability. The LPN should implement which precaution immediately?

Encourage ambulation to promote cervical ripening
Bed rest with continuous fetal monitoring and sterile speculum exam by RN/provider (Correct answer)
Prepare the client for immediate cesarean section
Perform a vaginal exam to assess cervical dilation

Correct answer: Bed rest with continuous fetal monitoring and sterile speculum exam by RN/provider

With premature rupture of membranes at 28 weeks, bed rest prevents cord prolapse, and continuous fetal monitoring detects cord compression. Vaginal exams (digital) are minimized to reduce infection risk.

Premature rupture of membranes (PROM) at 28 weeks is a high-risk situation. Risks include: cord prolapse (amniotic fluid cushion is gone), chorioamnionitis (infection), and preterm delivery. Nursing management: (1) Bed rest to prevent cord prolapse; (2) Continuous electronic fetal monitoring; (3) Sterile speculum examination to visualize the cervix and confirm membrane rupture (nitrazine test, ferning, pooling); (4) Digital vaginal exams are contraindicated unless delivery is imminent (increase infection risk); (5) Maternal vital signs every 4 hours (fever, tachycardia = infection); (6) Betamethasone for fetal lung maturity; (7) Antibiotics (group B Strep prophylaxis, latency antibiotics). Expectant management continues until term or signs of chorioamnionitis.

LPN Maternal and Neonatal Nursing 1

A client at 38 weeks gestation reports sudden, painless, bright red vaginal bleeding.
The LPN should first:

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