NURS 203 | NURS 203 Maternity Exam 4 Version 3
Questions with Correct Answers and Expert
Explanation for Each Question
1. A postpartum nurse is assessing a client two hours after a vaginal delivery and finds
the fundus to be boggy and displaced to the right. What is the nurse’s first priority
intervention?
A. Massage the fundus until firm.
B. Administer oxytocin as ordered.
C. Notify the healthcare provider immediately.
D. Assist the client to the bathroom to void.
Correct Answer: D
Expert Explanation: A displaced fundus to the right is a classic sign of bladder
distention which prevents the uterus from contracting effectively. Assisting the
client to void will allow the uterus to return to the midline and contract properly to
prevent hemorrhage. While fundal massage is important for a boggy uterus, the
displacement indicates the bladder is the primary cause of the issue. Effective
clinical reasoning dictates addressing the underlying cause of the displacement first.
This intervention promotes patient safety and prevents further postpartum
complications such as uterine atony.
,2. A newborn born at 38 weeks gestation to a mother with gestational diabetes is
found to be jittery and has a weak cry. Which action should the nurse take first?
A. Initiate breastfeeding immediately.
B. Wrap the newborn in a warm blanket.
C. Check the newborn’s blood glucose level.
D. Notify the neonatologist of the findings.
Correct Answer: C
Expert Explanation: Jitteriness and a weak cry are hallmark signs of neonatal
hypoglycemia, especially in infants of diabetic mothers. The nurse must prioritize
assessment by obtaining a bedside glucose measurement to confirm the condition.
Early identification is crucial to prevent neurological damage associated with
prolonged low blood sugar. Once hypoglycemia is confirmed, the nurse can proceed
with feeding or medical interventions. Monitoring high-risk newborns is a vital
component of neonatal safety and outcomes.
3. A nurse is caring for a client receiving Magnesium Sulfate for preeclampsia. Which
finding would require the nurse to stop the infusion immediately?
A. Blood pressure of 150/90 mmHg.
B. Urinary output of 40 mL per hour.
C. Deep tendon reflexes of 2+.
,D. Respiratory rate of 10 breaths per minute.
Correct Answer: D
Expert Explanation: Magnesium Sulfate is a central nervous system depressant,
and a respiratory rate below 12 indicates toxicity. Respiratory depression is a life-
threatening complication that necessitates the immediate cessation of the
medication. The nurse must also prepare to administer the antidote, calcium
gluconate, if necessary. Assessing reflexes and urine output is also part of the safety
monitoring protocol for these patients. Constant vigilance is required to ensure
maternal safety during the management of preeclampsia.
4. Which postpartum complication is characterized by a high fever, foul-smelling
lochia, and uterine tenderness occurring 48 hours after delivery?
A. Mastitis
B. Urinary tract infection
C. Thrombophlebitis
D. Endometritis
Correct Answer: D
Expert Explanation: Endometritis is an infection of the uterine lining and is the
most common cause of postpartum fever. The clinical presentation of foul-smelling
discharge and localized uterine pain is specific to this condition. It often requires
, intravenous antibiotics and careful monitoring of maternal vital signs. Prompt
treatment is necessary to prevent the spread of infection to the pelvic cavity or
bloodstream. Educating the patient on signs of infection before discharge is a key
nursing responsibility.
5. A nurse is providing discharge teaching to a mother regarding her newborn’s
umbilical cord care. Which statement by the mother indicates an understanding of the
teaching?
A. I will apply alcohol to the base of the cord with every diaper change.
B. I will give my baby a tub bath every day until the cord falls off.
C. I will keep the diaper folded down below the cord stump.
D. I will pull the cord off if it is hanging by a small thread.
Correct Answer: C
Expert Explanation: Keeping the diaper folded below the cord stump prevents
contamination from urine and allows the area to stay dry. Current evidence-based
practice suggests that cleaning with plain water and keeping the cord dry is
sufficient for healing. Tub baths should be avoided until the cord has completely
detached and the site is healed. The cord should never be pulled, as it must fall off
naturally to prevent bleeding. This teaching promotes neonatal safety and prevents
umbilical infections like omphalitis.
Questions with Correct Answers and Expert
Explanation for Each Question
1. A postpartum nurse is assessing a client two hours after a vaginal delivery and finds
the fundus to be boggy and displaced to the right. What is the nurse’s first priority
intervention?
A. Massage the fundus until firm.
B. Administer oxytocin as ordered.
C. Notify the healthcare provider immediately.
D. Assist the client to the bathroom to void.
Correct Answer: D
Expert Explanation: A displaced fundus to the right is a classic sign of bladder
distention which prevents the uterus from contracting effectively. Assisting the
client to void will allow the uterus to return to the midline and contract properly to
prevent hemorrhage. While fundal massage is important for a boggy uterus, the
displacement indicates the bladder is the primary cause of the issue. Effective
clinical reasoning dictates addressing the underlying cause of the displacement first.
This intervention promotes patient safety and prevents further postpartum
complications such as uterine atony.
,2. A newborn born at 38 weeks gestation to a mother with gestational diabetes is
found to be jittery and has a weak cry. Which action should the nurse take first?
A. Initiate breastfeeding immediately.
B. Wrap the newborn in a warm blanket.
C. Check the newborn’s blood glucose level.
D. Notify the neonatologist of the findings.
Correct Answer: C
Expert Explanation: Jitteriness and a weak cry are hallmark signs of neonatal
hypoglycemia, especially in infants of diabetic mothers. The nurse must prioritize
assessment by obtaining a bedside glucose measurement to confirm the condition.
Early identification is crucial to prevent neurological damage associated with
prolonged low blood sugar. Once hypoglycemia is confirmed, the nurse can proceed
with feeding or medical interventions. Monitoring high-risk newborns is a vital
component of neonatal safety and outcomes.
3. A nurse is caring for a client receiving Magnesium Sulfate for preeclampsia. Which
finding would require the nurse to stop the infusion immediately?
A. Blood pressure of 150/90 mmHg.
B. Urinary output of 40 mL per hour.
C. Deep tendon reflexes of 2+.
,D. Respiratory rate of 10 breaths per minute.
Correct Answer: D
Expert Explanation: Magnesium Sulfate is a central nervous system depressant,
and a respiratory rate below 12 indicates toxicity. Respiratory depression is a life-
threatening complication that necessitates the immediate cessation of the
medication. The nurse must also prepare to administer the antidote, calcium
gluconate, if necessary. Assessing reflexes and urine output is also part of the safety
monitoring protocol for these patients. Constant vigilance is required to ensure
maternal safety during the management of preeclampsia.
4. Which postpartum complication is characterized by a high fever, foul-smelling
lochia, and uterine tenderness occurring 48 hours after delivery?
A. Mastitis
B. Urinary tract infection
C. Thrombophlebitis
D. Endometritis
Correct Answer: D
Expert Explanation: Endometritis is an infection of the uterine lining and is the
most common cause of postpartum fever. The clinical presentation of foul-smelling
discharge and localized uterine pain is specific to this condition. It often requires
, intravenous antibiotics and careful monitoring of maternal vital signs. Prompt
treatment is necessary to prevent the spread of infection to the pelvic cavity or
bloodstream. Educating the patient on signs of infection before discharge is a key
nursing responsibility.
5. A nurse is providing discharge teaching to a mother regarding her newborn’s
umbilical cord care. Which statement by the mother indicates an understanding of the
teaching?
A. I will apply alcohol to the base of the cord with every diaper change.
B. I will give my baby a tub bath every day until the cord falls off.
C. I will keep the diaper folded down below the cord stump.
D. I will pull the cord off if it is hanging by a small thread.
Correct Answer: C
Expert Explanation: Keeping the diaper folded below the cord stump prevents
contamination from urine and allows the area to stay dry. Current evidence-based
practice suggests that cleaning with plain water and keeping the cord dry is
sufficient for healing. Tub baths should be avoided until the cord has completely
detached and the site is healed. The cord should never be pulled, as it must fall off
naturally to prevent bleeding. This teaching promotes neonatal safety and prevents
umbilical infections like omphalitis.
