NURS 316L | NURS316L Exam 3: OB Clinical - WCU
Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is assessing a client 12 hours postpartum and finds the fundus is firm and located
at the level of the umbilicus. What is the most appropriate nursing action?
A. Document the finding as normal.
B. Perform vigorous fundal massage.
C. Notify the healthcare provider immediately.
D. Assist the client to the bathroom to void.
Correct Answer: A
Rationale: Approximately 12 hours after birth, the fundus is typically found at the level of
the umbilicus. A firm fundus indicates that the uterine muscles are contracting effectively
to compress blood vessels. This finding is considered a normal part of the uterine
involution process. Because the finding is expected, the nurse should simply record it in the
medical record. No further interventions like massage or notification are required at this
time.
2. A newborn’s APGAR score is being calculated at 1 minute. The infant has a heart rate of
110, a weak cry, some flexion of extremities, grimace when stimulated, and a pink body with
blue extremities. What is the score?
A. 5
B. 7
C. 6
D. 8
Correct Answer: C
Rationale: The APGAR score is calculated based on five criteria including heart rate,
respiratory effort, muscle tone, reflex irritability, and color. This infant receives 2 points for
heart rate, 1 for weak cry, 1 for flexion, 1 for grimace, and 1 for acrocyanosis. Summing
these values results in a total score of 6 for the first minute of life. A score between 4 and 6
indicates that the newborn may require some resuscitation or close monitoring. Nurses
must perform this assessment accurately to determine the level of immediate neonatal care
needed.
3. A postpartum client is experiencing heavy lochia rubra with several large clots. What is the
priority nursing intervention?
A. Administer an analgesic for pain.
,B. Palpate the fundus for firmness.
C. Check the client’s blood pressure.
D. Increase the rate of intravenous fluids.
Correct Answer: B
Rationale: The first step in assessing postpartum hemorrhage is to evaluate the status of
the uterus. Uterine atony is the most common cause of excessive bleeding after childbirth.
Massaging a boggy fundus helps stimulate contractions and reduces blood loss from the
placental site. While vital signs are important, they often change only after significant blood
loss has occurred. Therefore, immediate fundal palpation and massage take priority over
other assessments or interventions.
4. Which finding during a newborn assessment should the nurse report to the provider as a
potential sign of respiratory distress?
A. Abdominal breathing
B. Nasal flaring
C. Respiratory rate of 45 breaths/min
D. Short periods of apnea lasting 5 seconds
Correct Answer: B
Rationale: Nasal flaring is a classic sign of increased work of breathing in a neonate. Other
signs of distress include grunting, retractions, and cyanosis. Normal newborn respirations
are typically between 30 to 60 breaths per minute and are diaphragmatic. Brief periods of
periodic breathing are normal as long as they do not exceed 20 seconds. Recognizing these
subtle signs of distress allows for early intervention and better neonatal outcomes.
5. A nurse is teaching a new mother about breastfeeding. Which statement by the mother
indicates an understanding of the proper latch?
A. “I should hear a clicking sound when the baby is sucking.”
B. “The baby’s nose and chin should be touching my breast.”
C. “Only the tip of my nipple should be in the baby’s mouth.”
D. “I should feel a sharp pinching sensation during the feeding.”
Correct Answer: B
Rationale: A deep latch is essential for effective milk transfer and the prevention of nipple
trauma. The infant’s mouth should cover most of the areola, not just the nipple tip. Clicking
sounds or sharp pain are indicators of a poor latch and improper positioning. When
correctly latched, the baby’s chin and nose are usually in close contact with the breast
, tissue. Ensuring a proper latch helps the mother maintain a successful and comfortable
breastfeeding experience.
6. During the first hour after delivery, the nurse notes the client’s fundus is displaced to the
right of the midline. What should the nurse do first?
A. Massage the fundus.
B. Call the physician.
C. Encourage the client to void.
D. Administer oxytocin.
Correct Answer: C
Rationale: A full bladder can displace the uterus and prevent it from contracting
effectively. When the fundus is found above the umbilicus or shifted to the side, it is most
often due to bladder distention. Having the client empty her bladder allows the uterus to
return to its proper midline position. This intervention is crucial for preventing uterine
atony and subsequent postpartum hemorrhage. After voiding, the nurse should re-evaluate
the fundal height and firmness.
7. Which newborn heat loss mechanism is prevented by drying the infant immediately after
birth?
A. Conduction
B. Evaporation
C. Convection
D. Radiation
Correct Answer: B
Rationale: Evaporation occurs when moisture on the skin is converted into vapor, drawing
heat away from the body. Because newborns are born wet, they are highly susceptible to
rapid heat loss through this mechanism. Drying the baby immediately and removing wet
linens is the most effective way to stop this process. Maintaining thermoregulation is vital
to prevent cold stress and metabolic complications in the neonate. This simple nursing
action is a priority step in the initial stabilization of the newborn.
8. A client who is 2 days postpartum asks why she is sweating so much at night. What is the
nurse’s best response?
A. “This is a sign of an underlying infection.”
B. “This is likely an allergic reaction to your medications.”
C. “Your body is getting rid of excess fluid from pregnancy.”
D. “Your thyroid levels are likely elevated after birth.”
Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is assessing a client 12 hours postpartum and finds the fundus is firm and located
at the level of the umbilicus. What is the most appropriate nursing action?
A. Document the finding as normal.
B. Perform vigorous fundal massage.
C. Notify the healthcare provider immediately.
D. Assist the client to the bathroom to void.
Correct Answer: A
Rationale: Approximately 12 hours after birth, the fundus is typically found at the level of
the umbilicus. A firm fundus indicates that the uterine muscles are contracting effectively
to compress blood vessels. This finding is considered a normal part of the uterine
involution process. Because the finding is expected, the nurse should simply record it in the
medical record. No further interventions like massage or notification are required at this
time.
2. A newborn’s APGAR score is being calculated at 1 minute. The infant has a heart rate of
110, a weak cry, some flexion of extremities, grimace when stimulated, and a pink body with
blue extremities. What is the score?
A. 5
B. 7
C. 6
D. 8
Correct Answer: C
Rationale: The APGAR score is calculated based on five criteria including heart rate,
respiratory effort, muscle tone, reflex irritability, and color. This infant receives 2 points for
heart rate, 1 for weak cry, 1 for flexion, 1 for grimace, and 1 for acrocyanosis. Summing
these values results in a total score of 6 for the first minute of life. A score between 4 and 6
indicates that the newborn may require some resuscitation or close monitoring. Nurses
must perform this assessment accurately to determine the level of immediate neonatal care
needed.
3. A postpartum client is experiencing heavy lochia rubra with several large clots. What is the
priority nursing intervention?
A. Administer an analgesic for pain.
,B. Palpate the fundus for firmness.
C. Check the client’s blood pressure.
D. Increase the rate of intravenous fluids.
Correct Answer: B
Rationale: The first step in assessing postpartum hemorrhage is to evaluate the status of
the uterus. Uterine atony is the most common cause of excessive bleeding after childbirth.
Massaging a boggy fundus helps stimulate contractions and reduces blood loss from the
placental site. While vital signs are important, they often change only after significant blood
loss has occurred. Therefore, immediate fundal palpation and massage take priority over
other assessments or interventions.
4. Which finding during a newborn assessment should the nurse report to the provider as a
potential sign of respiratory distress?
A. Abdominal breathing
B. Nasal flaring
C. Respiratory rate of 45 breaths/min
D. Short periods of apnea lasting 5 seconds
Correct Answer: B
Rationale: Nasal flaring is a classic sign of increased work of breathing in a neonate. Other
signs of distress include grunting, retractions, and cyanosis. Normal newborn respirations
are typically between 30 to 60 breaths per minute and are diaphragmatic. Brief periods of
periodic breathing are normal as long as they do not exceed 20 seconds. Recognizing these
subtle signs of distress allows for early intervention and better neonatal outcomes.
5. A nurse is teaching a new mother about breastfeeding. Which statement by the mother
indicates an understanding of the proper latch?
A. “I should hear a clicking sound when the baby is sucking.”
B. “The baby’s nose and chin should be touching my breast.”
C. “Only the tip of my nipple should be in the baby’s mouth.”
D. “I should feel a sharp pinching sensation during the feeding.”
Correct Answer: B
Rationale: A deep latch is essential for effective milk transfer and the prevention of nipple
trauma. The infant’s mouth should cover most of the areola, not just the nipple tip. Clicking
sounds or sharp pain are indicators of a poor latch and improper positioning. When
correctly latched, the baby’s chin and nose are usually in close contact with the breast
, tissue. Ensuring a proper latch helps the mother maintain a successful and comfortable
breastfeeding experience.
6. During the first hour after delivery, the nurse notes the client’s fundus is displaced to the
right of the midline. What should the nurse do first?
A. Massage the fundus.
B. Call the physician.
C. Encourage the client to void.
D. Administer oxytocin.
Correct Answer: C
Rationale: A full bladder can displace the uterus and prevent it from contracting
effectively. When the fundus is found above the umbilicus or shifted to the side, it is most
often due to bladder distention. Having the client empty her bladder allows the uterus to
return to its proper midline position. This intervention is crucial for preventing uterine
atony and subsequent postpartum hemorrhage. After voiding, the nurse should re-evaluate
the fundal height and firmness.
7. Which newborn heat loss mechanism is prevented by drying the infant immediately after
birth?
A. Conduction
B. Evaporation
C. Convection
D. Radiation
Correct Answer: B
Rationale: Evaporation occurs when moisture on the skin is converted into vapor, drawing
heat away from the body. Because newborns are born wet, they are highly susceptible to
rapid heat loss through this mechanism. Drying the baby immediately and removing wet
linens is the most effective way to stop this process. Maintaining thermoregulation is vital
to prevent cold stress and metabolic complications in the neonate. This simple nursing
action is a priority step in the initial stabilization of the newborn.
8. A client who is 2 days postpartum asks why she is sweating so much at night. What is the
nurse’s best response?
A. “This is a sign of an underlying infection.”
B. “This is likely an allergic reaction to your medications.”
C. “Your body is getting rid of excess fluid from pregnancy.”
D. “Your thyroid levels are likely elevated after birth.”
