NUR 202/NUR202 Exam 4 V1 | Maternal-
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a postpartum client 4 hours after a vaginal delivery and notes a firm
fundus but steady, bright red trickling of blood from the vagina. Which of the following
should the nurse suspect?
A. Uterine atony
B. Retained placental fragments
C. Laceration of the genital tract
D. Normal lochia rubra
Correct Answer: C
Expert Explanation: Steady trickling of bright red blood in the presence of a firm,
contracted uterus is a classic sign of a cervical or vaginal laceration. Uterine atony would
typically present with a boggy or soft fundus rather than a firm one. The nurse must report
this finding to the healthcare provider immediately for further inspection and repair to
prevent excessive blood loss.
2. When assessing a newborn 1 hour after birth, the nurse notes blue tinting of the hands and
feet, while the trunk remains pink. What is the appropriate nursing action?
A. Apply oxygen via bag-valve mask
,B. Notify the pediatrician of potential cyanosis
C. Document the finding as acrocyanosis
D. Place the newborn in a radiant warmer immediately
Correct Answer: C
Expert Explanation: Acrocyanosis is a normal finding in the first 24 to 48 hours of life due
to vasomotor instability and poor peripheral circulation. It is characterized by bluish
discoloration of the extremities while the central body remains pink. The nurse should
document this as a normal physiological transition and continue to monitor the newborn’s
temperature.
3. A postpartum nurse is caring for a client who is Rh-negative and has just delivered an Rh-
positive infant. Which action should the nurse take?
A. Check the mother’s blood type again in 1 week
B. Administer Rho(D) immune globulin to the infant within 24 hours
C. Administer Rho(D) immune globulin within 72 hours of delivery
D. Advise the mother she will not need Rhogam for future pregnancies
Correct Answer: C
Expert Explanation: Rho(D) immune globulin is administered to Rh-negative mothers
who give birth to Rh-positive infants to prevent sensitization. The medication must be
given intramuscularly within 72 hours of delivery to be effective for future pregnancies.
,This prevents the mother’s immune system from developing antibodies that could attack
the red blood cells of a future Rh-positive fetus.
4. The nurse is teaching a new mother about breastfeeding. Which statement by the mother
indicates a need for further teaching?
A. I should wash my nipples with soap and water before each feeding
B. I will nurse my baby every 2 to 3 hours or on demand
C. The baby’s nose should be close to my breast but not blocked
D. I should hear the baby swallowing during the feeding
Correct Answer: A
Expert Explanation: The mother should avoid using soap on her nipples because it can
cause excessive drying and cracking by removing natural oils. Instead, she should wash
with plain water or simply allow breast milk to dry on the nipple for its antibacterial
properties. Feeding on demand every 2-3 hours and monitoring for swallowing are correct
breastfeeding practices that indicate a good latch and milk transfer.
5. A newborn has an APGAR score of 9 at 1 minute and 10 at 5 minutes. How should the nurse
interpret these findings?
A. The newborn is experiencing moderate respiratory distress
B. The newborn requires immediate resuscitation
C. The newborn is showing excellent transition to extrauterine life
, D. The newborn has central cyanosis and needs oxygen
Correct Answer: C
Expert Explanation: An APGAR score between 7 and 10 indicates that the newborn is in
good condition and is successfully adjusting to extrauterine life. The score assesses heart
rate, respiratory effort, muscle tone, reflex irritability, and color. Since the scores are near
the maximum, no interventions other than routine care and monitoring are required.
6. A nurse is assessing a client 12 hours postpartum and finds the fundus is 2 cm above the
umbilicus and displaced to the right. What is the priority nursing intervention?
A. Perform vigorous fundal massage
B. Notify the healthcare provider immediately
C. Assist the client to the bathroom to void
D. Administer an oxytocic medication
Correct Answer: C
Expert Explanation: A fundus that is elevated above the umbilicus and displaced to the
right is most commonly caused by a distended bladder. A full bladder prevents the uterus
from contracting properly, which can lead to uterine atony and hemorrhage. Emptying the
bladder allows the uterus to return to the midline and contract effectively to control
bleeding.
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a postpartum client 4 hours after a vaginal delivery and notes a firm
fundus but steady, bright red trickling of blood from the vagina. Which of the following
should the nurse suspect?
A. Uterine atony
B. Retained placental fragments
C. Laceration of the genital tract
D. Normal lochia rubra
Correct Answer: C
Expert Explanation: Steady trickling of bright red blood in the presence of a firm,
contracted uterus is a classic sign of a cervical or vaginal laceration. Uterine atony would
typically present with a boggy or soft fundus rather than a firm one. The nurse must report
this finding to the healthcare provider immediately for further inspection and repair to
prevent excessive blood loss.
2. When assessing a newborn 1 hour after birth, the nurse notes blue tinting of the hands and
feet, while the trunk remains pink. What is the appropriate nursing action?
A. Apply oxygen via bag-valve mask
,B. Notify the pediatrician of potential cyanosis
C. Document the finding as acrocyanosis
D. Place the newborn in a radiant warmer immediately
Correct Answer: C
Expert Explanation: Acrocyanosis is a normal finding in the first 24 to 48 hours of life due
to vasomotor instability and poor peripheral circulation. It is characterized by bluish
discoloration of the extremities while the central body remains pink. The nurse should
document this as a normal physiological transition and continue to monitor the newborn’s
temperature.
3. A postpartum nurse is caring for a client who is Rh-negative and has just delivered an Rh-
positive infant. Which action should the nurse take?
A. Check the mother’s blood type again in 1 week
B. Administer Rho(D) immune globulin to the infant within 24 hours
C. Administer Rho(D) immune globulin within 72 hours of delivery
D. Advise the mother she will not need Rhogam for future pregnancies
Correct Answer: C
Expert Explanation: Rho(D) immune globulin is administered to Rh-negative mothers
who give birth to Rh-positive infants to prevent sensitization. The medication must be
given intramuscularly within 72 hours of delivery to be effective for future pregnancies.
,This prevents the mother’s immune system from developing antibodies that could attack
the red blood cells of a future Rh-positive fetus.
4. The nurse is teaching a new mother about breastfeeding. Which statement by the mother
indicates a need for further teaching?
A. I should wash my nipples with soap and water before each feeding
B. I will nurse my baby every 2 to 3 hours or on demand
C. The baby’s nose should be close to my breast but not blocked
D. I should hear the baby swallowing during the feeding
Correct Answer: A
Expert Explanation: The mother should avoid using soap on her nipples because it can
cause excessive drying and cracking by removing natural oils. Instead, she should wash
with plain water or simply allow breast milk to dry on the nipple for its antibacterial
properties. Feeding on demand every 2-3 hours and monitoring for swallowing are correct
breastfeeding practices that indicate a good latch and milk transfer.
5. A newborn has an APGAR score of 9 at 1 minute and 10 at 5 minutes. How should the nurse
interpret these findings?
A. The newborn is experiencing moderate respiratory distress
B. The newborn requires immediate resuscitation
C. The newborn is showing excellent transition to extrauterine life
, D. The newborn has central cyanosis and needs oxygen
Correct Answer: C
Expert Explanation: An APGAR score between 7 and 10 indicates that the newborn is in
good condition and is successfully adjusting to extrauterine life. The score assesses heart
rate, respiratory effort, muscle tone, reflex irritability, and color. Since the scores are near
the maximum, no interventions other than routine care and monitoring are required.
6. A nurse is assessing a client 12 hours postpartum and finds the fundus is 2 cm above the
umbilicus and displaced to the right. What is the priority nursing intervention?
A. Perform vigorous fundal massage
B. Notify the healthcare provider immediately
C. Assist the client to the bathroom to void
D. Administer an oxytocic medication
Correct Answer: C
Expert Explanation: A fundus that is elevated above the umbilicus and displaced to the
right is most commonly caused by a distended bladder. A full bladder prevents the uterus
from contracting properly, which can lead to uterine atony and hemorrhage. Emptying the
bladder allows the uterus to return to the midline and contract effectively to control
bleeding.
