NURS 203 | NURS 203 Maternity Exam 4 Version 1 |
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A nurse is assessing a client 12 hours postpartum and finds the fundus is firm,
midline, and at the level of the umbilicus. What is the most appropriate nursing
action?
A. Document the finding as normal.
B. Massage the fundus vigorously.
C. Notify the healthcare provider immediately.
D. Assist the client to the bathroom to void.
Correct Answer: A
Expert Explanation: Normal uterine involution involves the fundus rising to the
level of the umbilicus within the first 12 hours after birth. A firm and midline fundus
indicates that the uterine muscles are contracting effectively to prevent
hemorrhage. At this stage, no further intervention other than documentation is
required because the findings are within expected parameters. Vigorous massage is
only necessary if the fundus is boggy or soft. This assessment confirms the body is
correctly beginning the recovery process.
,2. Which clinical finding should the nurse prioritize as a potential sign of postpartum
hemorrhage?
A. Pulse rate of 60 beats per minute.
B. Temperature of 100.2°F (37.9°C).
C. Lochia rubra with small clots.
D. Saturating a perineal pad in 15 minutes.
Correct Answer: D
Expert Explanation: Saturating a perineal pad in 15 minutes or less is a classic sign
of excessive bleeding and potential hemorrhage. While small clots and lochia rubra
are normal in the early postpartum period, rapid saturation requires immediate
intervention. Bradycardia is actually a common physiological adaptation
postpartum, and a slight temperature elevation is often due to dehydration. The
nurse must prioritize excessive blood loss to prevent hypovolemic shock. Prompt
fundal massage and assessment of bladder status are the next vital steps.
3. A postpartum client who is not breastfeeding asks the nurse how to treat breast
engorgement. Which instruction is correct?
A. Express small amounts of milk manually.
B. Apply warm compresses to the breasts.
C. Stimulate the nipples while showering.
,D. Apply fresh, cold cabbage leaves to the breasts.
Correct Answer: D
Expert Explanation: Cold cabbage leaves contain enzymes that help reduce
swelling and provide comfort for non-breastfeeding mothers. For those not
lactating, it is crucial to avoid any nipple stimulation or heat, which would
encourage milk production. Manual expression should also be avoided as it triggers
the body to produce more milk. Wearing a tight-fitting, supportive bra is another
effective non-pharmacological intervention for engorgement. This approach focuses
on suppressing lactation through comfort measures and lack of stimulation.
4. During an assessment, the nurse finds the fundus is boggy and displaced to the
right. What is the first nursing action?
A. Administer oxytocin as ordered.
B. Perform a fundal massage.
C. Have the client empty her bladder.
D. Check the client’s blood pressure.
Correct Answer: C
Expert Explanation: A fundus that is displaced to the right is a hallmark sign of a
distended bladder. A full bladder prevents the uterus from contracting efficiently,
which leads to a boggy consistency and increased bleeding risk. Therefore, having
, the client void is the most effective first step to return the uterus to the midline and
firm it up. If the fundus remains boggy after voiding, massage would then be
indicated. Prioritizing bladder emptying addresses the root cause of the
displacement.
5. Which phase of maternal adjustment is characterized by the mother being talkative
and focusing on her birth experience?
A. Letting-go phase
B. Taking-hold phase
C. Taking-in phase
D. Transition phase
Correct Answer: C
Expert Explanation: The ‘Taking-in’ phase occurs in the first 24 to 48 hours after
birth when the mother is often passive and dependent. During this time, she
frequently reviews her labor and birth story to integrate the experience into her
reality. Her primary focus is on her own needs for food, sleep, and physical comfort.
This phase is followed by the ‘Taking-hold’ phase where she becomes more
independent in infant care. Understanding these psychological stages helps the
nurse provide appropriate emotional support.
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A nurse is assessing a client 12 hours postpartum and finds the fundus is firm,
midline, and at the level of the umbilicus. What is the most appropriate nursing
action?
A. Document the finding as normal.
B. Massage the fundus vigorously.
C. Notify the healthcare provider immediately.
D. Assist the client to the bathroom to void.
Correct Answer: A
Expert Explanation: Normal uterine involution involves the fundus rising to the
level of the umbilicus within the first 12 hours after birth. A firm and midline fundus
indicates that the uterine muscles are contracting effectively to prevent
hemorrhage. At this stage, no further intervention other than documentation is
required because the findings are within expected parameters. Vigorous massage is
only necessary if the fundus is boggy or soft. This assessment confirms the body is
correctly beginning the recovery process.
,2. Which clinical finding should the nurse prioritize as a potential sign of postpartum
hemorrhage?
A. Pulse rate of 60 beats per minute.
B. Temperature of 100.2°F (37.9°C).
C. Lochia rubra with small clots.
D. Saturating a perineal pad in 15 minutes.
Correct Answer: D
Expert Explanation: Saturating a perineal pad in 15 minutes or less is a classic sign
of excessive bleeding and potential hemorrhage. While small clots and lochia rubra
are normal in the early postpartum period, rapid saturation requires immediate
intervention. Bradycardia is actually a common physiological adaptation
postpartum, and a slight temperature elevation is often due to dehydration. The
nurse must prioritize excessive blood loss to prevent hypovolemic shock. Prompt
fundal massage and assessment of bladder status are the next vital steps.
3. A postpartum client who is not breastfeeding asks the nurse how to treat breast
engorgement. Which instruction is correct?
A. Express small amounts of milk manually.
B. Apply warm compresses to the breasts.
C. Stimulate the nipples while showering.
,D. Apply fresh, cold cabbage leaves to the breasts.
Correct Answer: D
Expert Explanation: Cold cabbage leaves contain enzymes that help reduce
swelling and provide comfort for non-breastfeeding mothers. For those not
lactating, it is crucial to avoid any nipple stimulation or heat, which would
encourage milk production. Manual expression should also be avoided as it triggers
the body to produce more milk. Wearing a tight-fitting, supportive bra is another
effective non-pharmacological intervention for engorgement. This approach focuses
on suppressing lactation through comfort measures and lack of stimulation.
4. During an assessment, the nurse finds the fundus is boggy and displaced to the
right. What is the first nursing action?
A. Administer oxytocin as ordered.
B. Perform a fundal massage.
C. Have the client empty her bladder.
D. Check the client’s blood pressure.
Correct Answer: C
Expert Explanation: A fundus that is displaced to the right is a hallmark sign of a
distended bladder. A full bladder prevents the uterus from contracting efficiently,
which leads to a boggy consistency and increased bleeding risk. Therefore, having
, the client void is the most effective first step to return the uterus to the midline and
firm it up. If the fundus remains boggy after voiding, massage would then be
indicated. Prioritizing bladder emptying addresses the root cause of the
displacement.
5. Which phase of maternal adjustment is characterized by the mother being talkative
and focusing on her birth experience?
A. Letting-go phase
B. Taking-hold phase
C. Taking-in phase
D. Transition phase
Correct Answer: C
Expert Explanation: The ‘Taking-in’ phase occurs in the first 24 to 48 hours after
birth when the mother is often passive and dependent. During this time, she
frequently reviews her labor and birth story to integrate the experience into her
reality. Her primary focus is on her own needs for food, sleep, and physical comfort.
This phase is followed by the ‘Taking-hold’ phase where she becomes more
independent in infant care. Understanding these psychological stages helps the
nurse provide appropriate emotional support.
