NUR 230 Exam 3: OB/Peds - Galen College of Nursing
Updated and Latest Questions and Correct Answers with
Rationale
1. A nurse is assessing a postpartum client four hours after a vaginal delivery and finds the fundus is boggy
and displaced to the right. Which action should the nurse take first?
A. Administer oxytocin as prescribed
B. Perform fundal massage
C. Encourage the client to void
D. Notify the healthcare provider
Correct Answer: C
Rationale: A displaced and boggy fundus usually indicates that the bladder is full and pushing the uterus
out of place. Emptying the bladder allows the uterus to contract effectively and return to the midline.
While fundal massage is important for a boggy uterus, addressing the cause of displacement is the
priority here. Oxytocin is used for atony but is not the first step when a full bladder is suspected. Taking
immediate action to promote voiding prevents further postpartum hemorrhage complications.
2. The nurse is performing an APGAR score on a newborn at 1 minute. The infant has a heart rate of 110
bpm, a slow/irregular cry, some flexion of extremities, a grimace when suctioned, and a pink body with blue
extremities. What is the APGAR score?
A. 5
B. 7
C. 6
D. 8
,Correct Answer: C
Rationale: The infant receives 2 points for heart rate over 100 and 1 point for a slow cry. One point is
given for some flexion and 1 point for the grimace response to suctioning. The blue extremities
(acrocyanosis) with a pink body merit 1 point for color. Adding these values (2+1+1+1+1) results in a
total score of 6. This score indicates that the infant may require some resuscitation or close observation.
3. Which of the following is a characteristic sign of neonatal cold stress that the nurse should monitor for in
the nursery?
A. Increased respiratory rate
B. Decreased oxygen consumption
C. Hyperglycemia
D. Shivering
Correct Answer: A
Rationale: Newborns do not shiver to produce heat but instead use non-shivering thermogenesis via
brown fat metabolism. This metabolic process increases oxygen consumption and can lead to an
increased respiratory rate or respiratory distress. Hypoglycemia, rather than hyperglycemia, is a
common result of cold stress as glucose stores are depleted. Monitoring for tachypnea is essential to
identify early signs of thermoregulation failure. Effective warmth maintenance prevents the metabolic
acidosis associated with cold stress.
4. A mother who is breastfeeding asks about the color of her newborn’s stool on day 4. Which description
by the nurse accurately describes transitional stools?
A. Greenish-brown and thinner than meconium
B. Thick, tarry, and black
, C. Yellow and seedy
D. Pale yellow and pasty
Correct Answer: A
Rationale: Transitional stools typically appear by the third or fourth day of life as the infant begins
digesting milk. These stools are greenish-brown to yellowish-brown and have a thinner consistency than
the initial meconium. Meconium is the thick, black, tarry stool passed in the first 24 to 48 hours. Yellow,
seedy stools are characteristic of established breastfeeding later in the first week. Understanding stool
progression helps the nurse assess the newborn’s gastrointestinal transition and intake.
5. A nurse is caring for a newborn undergoing phototherapy for hyperbilirubinemia. Which intervention is
most important for the nurse to include in the plan of care?
A. Apply lotion to the skin to prevent drying
B. Cover the infant’s eyes with protective patches
C. Limit fluid intake to prevent diarrhea
D. Keep the infant in a shirt and diaper
Correct Answer: B
Rationale: Protective eye patches are mandatory to prevent retinal damage from the high-intensity
lights used in phototherapy. The nurse should ensure the infant is undressed, except for a diaper, to
maximize skin exposure to the light. Lotions should be avoided as they can cause burns on the skin under
the lights. Increasing fluid intake is actually encouraged to promote the excretion of bilirubin through
stool and urine. Regular assessment of the infant’s temperature and hydration status is also a critical
nursing responsibility.
Updated and Latest Questions and Correct Answers with
Rationale
1. A nurse is assessing a postpartum client four hours after a vaginal delivery and finds the fundus is boggy
and displaced to the right. Which action should the nurse take first?
A. Administer oxytocin as prescribed
B. Perform fundal massage
C. Encourage the client to void
D. Notify the healthcare provider
Correct Answer: C
Rationale: A displaced and boggy fundus usually indicates that the bladder is full and pushing the uterus
out of place. Emptying the bladder allows the uterus to contract effectively and return to the midline.
While fundal massage is important for a boggy uterus, addressing the cause of displacement is the
priority here. Oxytocin is used for atony but is not the first step when a full bladder is suspected. Taking
immediate action to promote voiding prevents further postpartum hemorrhage complications.
2. The nurse is performing an APGAR score on a newborn at 1 minute. The infant has a heart rate of 110
bpm, a slow/irregular cry, some flexion of extremities, a grimace when suctioned, and a pink body with blue
extremities. What is the APGAR score?
A. 5
B. 7
C. 6
D. 8
,Correct Answer: C
Rationale: The infant receives 2 points for heart rate over 100 and 1 point for a slow cry. One point is
given for some flexion and 1 point for the grimace response to suctioning. The blue extremities
(acrocyanosis) with a pink body merit 1 point for color. Adding these values (2+1+1+1+1) results in a
total score of 6. This score indicates that the infant may require some resuscitation or close observation.
3. Which of the following is a characteristic sign of neonatal cold stress that the nurse should monitor for in
the nursery?
A. Increased respiratory rate
B. Decreased oxygen consumption
C. Hyperglycemia
D. Shivering
Correct Answer: A
Rationale: Newborns do not shiver to produce heat but instead use non-shivering thermogenesis via
brown fat metabolism. This metabolic process increases oxygen consumption and can lead to an
increased respiratory rate or respiratory distress. Hypoglycemia, rather than hyperglycemia, is a
common result of cold stress as glucose stores are depleted. Monitoring for tachypnea is essential to
identify early signs of thermoregulation failure. Effective warmth maintenance prevents the metabolic
acidosis associated with cold stress.
4. A mother who is breastfeeding asks about the color of her newborn’s stool on day 4. Which description
by the nurse accurately describes transitional stools?
A. Greenish-brown and thinner than meconium
B. Thick, tarry, and black
, C. Yellow and seedy
D. Pale yellow and pasty
Correct Answer: A
Rationale: Transitional stools typically appear by the third or fourth day of life as the infant begins
digesting milk. These stools are greenish-brown to yellowish-brown and have a thinner consistency than
the initial meconium. Meconium is the thick, black, tarry stool passed in the first 24 to 48 hours. Yellow,
seedy stools are characteristic of established breastfeeding later in the first week. Understanding stool
progression helps the nurse assess the newborn’s gastrointestinal transition and intake.
5. A nurse is caring for a newborn undergoing phototherapy for hyperbilirubinemia. Which intervention is
most important for the nurse to include in the plan of care?
A. Apply lotion to the skin to prevent drying
B. Cover the infant’s eyes with protective patches
C. Limit fluid intake to prevent diarrhea
D. Keep the infant in a shirt and diaper
Correct Answer: B
Rationale: Protective eye patches are mandatory to prevent retinal damage from the high-intensity
lights used in phototherapy. The nurse should ensure the infant is undressed, except for a diaper, to
maximize skin exposure to the light. Lotions should be avoided as they can cause burns on the skin under
the lights. Increasing fluid intake is actually encouraged to promote the excretion of bilirubin through
stool and urine. Regular assessment of the infant’s temperature and hydration status is also a critical
nursing responsibility.
