NUR 202/NUR202 Exam 4 V2 | Maternal-
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a client 2 hours postpartum and notes the fundus is displaced to the
right and is boggy. Which of the following actions should the nurse take first?
A. Administer oxytocin via IV bolus.
B. Perform firm fundal massage.
C. Assist the client to the bathroom to void.
D. Notify the healthcare provider immediately.
Correct Answer: B
Expert Explanation: The first priority when a fundus is boggy is to perform fundal
massage to stimulate uterine contractions and prevent hemorrhage. A displaced fundus
often indicates a full bladder, which interferes with uterine involution. However, massage
must occur immediately to maintain clinical stability before assisting the client to void.
2. A nurse is providing discharge teaching to a client who is breastfeeding. Which of the
following statements by the client indicates an understanding of mastitis?
A. “I should stop breastfeeding if I develop a fever or redness in one breast.”
B. “Mastitis is usually caused by an infection in both breasts simultaneously.”
C. “I need to limit my fluid intake to reduce breast swelling.”
,D. “I should continue to breastfeed frequently to help clear the blockage.”
Correct Answer: D
Expert Explanation: Frequent emptying of the breast is essential in the treatment of
mastitis to prevent further stasis of milk. The client should be taught that breastfeeding is
safe for the infant and helps resolve the infection. Abruptly stopping breastfeeding can lead
to the formation of a breast abscess.
3. Which of the following findings should a nurse report to the provider when assessing a
newborn who is 12 hours old?
A. Jaundice of the face and sclera.
B. Acrocyanosis of the hands and feet.
C. Erythema toxicum on the trunk.
D. Respiratory rate of 50 breaths per minute.
Correct Answer: A
Expert Explanation: Jaundice appearing within the first 24 hours of life is considered
pathological and requires immediate investigation. Pathological jaundice is often related to
hemolytic disease or Rh incompatibility. In contrast, physiological jaundice typically
appears after 24 hours and is generally less concerning.
4. A nurse is caring for a newborn immediately following birth. Which of the following actions
is the priority to prevent heat loss via evaporation?
A. Placing the newborn on a pre-warmed radiant warmer.
, B. Placing the newborn skin-to-skin with the mother.
C. Putting a cap on the newborn’s head.
D. Drying the newborn thoroughly with warm blankets.
Correct Answer: D
Expert Explanation: Evaporative heat loss occurs when moisture on the skin is converted
to vapor, which is the most significant source of heat loss at birth. Drying the infant
immediately removes the amniotic fluid and prevents this cooling process. While other
methods like radiant warmers help, drying is the specific intervention for evaporation.
5. A client who is 3 days postpartum calls the clinic reporting feelings of sadness and crying
easily. Which of the following responses should the nurse provide?
A. “You should come in immediately as this sounds like postpartum psychosis.”
B. “You likely have a thyroid imbalance that needs to be tested.”
C. “We will need to start you on antidepressant medication right away.”
D. “These feelings are common and are known as the postpartum blues.”
Correct Answer: D
Expert Explanation: Postpartum blues occur in up to 80% of women and usually peak
around the third to fifth day after delivery. The symptoms are generally self-limiting and
resolve within 10 to 14 days without medical intervention. The nurse should provide
reassurance while also teaching the client to report if symptoms worsen or persist.
Newborn Nursing Q&A with Rationale |
Fortis College
1. A nurse is assessing a client 2 hours postpartum and notes the fundus is displaced to the
right and is boggy. Which of the following actions should the nurse take first?
A. Administer oxytocin via IV bolus.
B. Perform firm fundal massage.
C. Assist the client to the bathroom to void.
D. Notify the healthcare provider immediately.
Correct Answer: B
Expert Explanation: The first priority when a fundus is boggy is to perform fundal
massage to stimulate uterine contractions and prevent hemorrhage. A displaced fundus
often indicates a full bladder, which interferes with uterine involution. However, massage
must occur immediately to maintain clinical stability before assisting the client to void.
2. A nurse is providing discharge teaching to a client who is breastfeeding. Which of the
following statements by the client indicates an understanding of mastitis?
A. “I should stop breastfeeding if I develop a fever or redness in one breast.”
B. “Mastitis is usually caused by an infection in both breasts simultaneously.”
C. “I need to limit my fluid intake to reduce breast swelling.”
,D. “I should continue to breastfeed frequently to help clear the blockage.”
Correct Answer: D
Expert Explanation: Frequent emptying of the breast is essential in the treatment of
mastitis to prevent further stasis of milk. The client should be taught that breastfeeding is
safe for the infant and helps resolve the infection. Abruptly stopping breastfeeding can lead
to the formation of a breast abscess.
3. Which of the following findings should a nurse report to the provider when assessing a
newborn who is 12 hours old?
A. Jaundice of the face and sclera.
B. Acrocyanosis of the hands and feet.
C. Erythema toxicum on the trunk.
D. Respiratory rate of 50 breaths per minute.
Correct Answer: A
Expert Explanation: Jaundice appearing within the first 24 hours of life is considered
pathological and requires immediate investigation. Pathological jaundice is often related to
hemolytic disease or Rh incompatibility. In contrast, physiological jaundice typically
appears after 24 hours and is generally less concerning.
4. A nurse is caring for a newborn immediately following birth. Which of the following actions
is the priority to prevent heat loss via evaporation?
A. Placing the newborn on a pre-warmed radiant warmer.
, B. Placing the newborn skin-to-skin with the mother.
C. Putting a cap on the newborn’s head.
D. Drying the newborn thoroughly with warm blankets.
Correct Answer: D
Expert Explanation: Evaporative heat loss occurs when moisture on the skin is converted
to vapor, which is the most significant source of heat loss at birth. Drying the infant
immediately removes the amniotic fluid and prevents this cooling process. While other
methods like radiant warmers help, drying is the specific intervention for evaporation.
5. A client who is 3 days postpartum calls the clinic reporting feelings of sadness and crying
easily. Which of the following responses should the nurse provide?
A. “You should come in immediately as this sounds like postpartum psychosis.”
B. “You likely have a thyroid imbalance that needs to be tested.”
C. “We will need to start you on antidepressant medication right away.”
D. “These feelings are common and are known as the postpartum blues.”
Correct Answer: D
Expert Explanation: Postpartum blues occur in up to 80% of women and usually peak
around the third to fifth day after delivery. The symptoms are generally self-limiting and
resolve within 10 to 14 days without medical intervention. The nurse should provide
reassurance while also teaching the client to report if symptoms worsen or persist.
