NU 170 EXAM 4/300 ACTUAL QUESTIONS AND
CORRECT ANSWERS WITH RATIONALE
LATEST UPDATE ALREADY GRADED A+
ASSURED PASS
This extensive question bank covers the essential content for a maternal-child
nursing final exam, integrating both obstetrics and pediatrics. The 300 questions
are systematically organized into ten sections, ranging from postpartum
complications and newborn assessment to pediatric growth, respiratory disorders,
and complex endocrine conditions. Each question is designed to test clinical
judgment, prioritization, and application of nursing interventions. The inclusion of
detailed rationales reinforces understanding of pathophysiology and evidence-
based care. This comprehensive resource serves as an effective study tool for
students, helping them identify knowledge gaps and prepare for high-stakes
nursing examinations by simulating real NCLEX-style questions with a strong
emphasis on safety and family-centered care.
Section 1: Postpartum Assessment and Complications (Questions 1-30)
1. A nurse is assessing a client who is 4 hours postpartum and observes heavy
lochia rubra. The client is alert and oriented. Which action should the nurse
perform first?
A) Change the client's perineal pad
B) Administer oxygen
C) Palpate the bladder and have the client void if full
D) Call the provider
Answer: C
Rationale: A boggy uterus displaced to the right often indicates a full bladder,
which prevents effective uterine contraction. The nurse should first have the client
void and reassess fundal firmness. Oxygen is not indicated, and calling the
provider comes after assessment and intervention.
,2. A postpartum client reports that her lochia has changed from pink to bright red
and is now heavy. What is the nurse's priority action?
A) Document as a normal finding
B) Encourage the client to ambulate
C) Assess the fundus and notify the provider
D) Administer oxytocin as prescribed
Answer: C
Rationale: A sudden change from pink to bright red with increased flow is a sign of
potential postpartum hemorrhage. The nurse must assess the fundus for tone and
notify the provider immediately.
3. A client who is 2 days postpartum has a fundus that is boggy and displaced to
the right. What should the nurse assess first?
A) Pain level
B) Bladder distention
C) Bowel sounds
D) Vital signs
Answer: B
Rationale: A boggy, soft uterus displaced to the right suggests a full bladder
pushing the uterus upward. A full bladder prevents effective contraction and
increases hemorrhage risk.
4. A nurse is caring for a client who is exhibiting signs of postpartum hemorrhage.
The client's blood pressure is 94/58 mm Hg, pulse is 112, and the client has
saturated 1 peri pad in 30 minutes. After massaging the fundus, which action is
most appropriate?
A) Administer oxytocin
B) Call the provider
C) Increase IV fluids
D) Apply oxygen
Answer: A
Rationale: Oxytocin is a uterotonic medication used to manage postpartum
hemorrhage caused by uterine atony. Massaging the fundus and administering
oxytocin are priority interventions.
5. A nurse is monitoring a postpartum client who had a vaginal delivery. Which
finding would indicate uterine atony?
A) Firm fundus at the umbilicus
B) Boggy fundus that does not respond to massage
C) Fundus located below the umbilicus
,D) Moderate lochia rubra
Answer: B
Rationale: Uterine atony presents as a boggy, soft uterus that fails to respond to
massage. This indicates poor uterine muscle tone and is a leading cause of
postpartum hemorrhage.
6. A nurse is assessing a client who is 24 hours postpartum. Which finding is most
important for the nurse to follow up?
A) Temperature of 99.0°F
B) Trickle of bright red blood
C) Fundus firm at the umbilicus
D) Moderate lochia rubra
Answer: B
Rationale: A trickle of bright red blood can indicate a laceration or hematoma,
even with a firm fundus. This requires further assessment and provider notification.
7. A nurse is reinforcing teaching with a client who has mastitis about self-care.
Which instruction indicates correct understanding?
A) Apply cold compress to the breast prior to feeding
B) Breastfeed from the infected side first
C) Stop breastfeeding until infection resolves
D) Apply heat after feeding
Answer: A
Rationale: Applying cold compresses before feeding can help reduce pain and
swelling. The client should continue breastfeeding from the uninfected side first,
then the infected side, and apply heat before feeding to promote milk flow.
8. A nurse is caring for a postpartum client with endometritis. Which nursing
action by a newly hired nurse requires immediate intervention?
A) Administering prescribed antibiotics
B) Encouraging the client to use a douche
C) Monitoring vital signs
D) Assessing fundal tone
Answer: B
Rationale: Douching is contraindicated in endometritis as it can introduce bacteria
and worsen infection. The nurse should intervene immediately to stop this practice.
9. A postpartum client reports painful, swollen breasts on day 3. She is formula
feeding her infant. Which action should the nurse encourage?
A) Pump the breasts to relieve discomfort
, B) Wear a supportive bra
C) Apply warm compresses
D) Massage the breasts
Answer: B
Rationale: For formula-feeding mothers with engorgement, wearing a supportive
bra, applying cold packs, and avoiding breast stimulation are recommended.
Pumping would stimulate more milk production.
10. A nurse is caring for a client following a cesarean delivery. Which intervention
should be recommended for the prevention of venous thrombosis?
A) Administer low molecular weight heparin
B) Encourage early ambulation
C) Apply sequential compression devices
D) All of the above
Answer: D
Rationale: Prevention of venous thrombosis includes early ambulation, sequential
compression devices, and prophylactic anticoagulants such as low molecular
weight heparin.
11. At 24 hours postpartum, which finding is most important for the nurse to
address?
A) A slightly firm uterus
B) Perineal pad saturated every 5 hours
C) Temperature of 99.0°F
D) Total urine voided 1500 mL
Answer: B
Rationale: Saturating a perineal pad every 5 hours indicates heavy bleeding
requiring further assessment. This is a priority finding.
12. A nurse is assessing a postpartum client and notes heavy lochia rubra with
clots. The fundus is firm and midline. What should the nurse suspect?
A) Uterine atony
B) Retained placental fragments
C) Laceration or hematoma
D) Normal finding
Answer: C
Rationale: When the fundus is firm but heavy bleeding persists, the cause may be a
laceration or hematoma. The nurse should assess the perineum and notify the
provider.
CORRECT ANSWERS WITH RATIONALE
LATEST UPDATE ALREADY GRADED A+
ASSURED PASS
This extensive question bank covers the essential content for a maternal-child
nursing final exam, integrating both obstetrics and pediatrics. The 300 questions
are systematically organized into ten sections, ranging from postpartum
complications and newborn assessment to pediatric growth, respiratory disorders,
and complex endocrine conditions. Each question is designed to test clinical
judgment, prioritization, and application of nursing interventions. The inclusion of
detailed rationales reinforces understanding of pathophysiology and evidence-
based care. This comprehensive resource serves as an effective study tool for
students, helping them identify knowledge gaps and prepare for high-stakes
nursing examinations by simulating real NCLEX-style questions with a strong
emphasis on safety and family-centered care.
Section 1: Postpartum Assessment and Complications (Questions 1-30)
1. A nurse is assessing a client who is 4 hours postpartum and observes heavy
lochia rubra. The client is alert and oriented. Which action should the nurse
perform first?
A) Change the client's perineal pad
B) Administer oxygen
C) Palpate the bladder and have the client void if full
D) Call the provider
Answer: C
Rationale: A boggy uterus displaced to the right often indicates a full bladder,
which prevents effective uterine contraction. The nurse should first have the client
void and reassess fundal firmness. Oxygen is not indicated, and calling the
provider comes after assessment and intervention.
,2. A postpartum client reports that her lochia has changed from pink to bright red
and is now heavy. What is the nurse's priority action?
A) Document as a normal finding
B) Encourage the client to ambulate
C) Assess the fundus and notify the provider
D) Administer oxytocin as prescribed
Answer: C
Rationale: A sudden change from pink to bright red with increased flow is a sign of
potential postpartum hemorrhage. The nurse must assess the fundus for tone and
notify the provider immediately.
3. A client who is 2 days postpartum has a fundus that is boggy and displaced to
the right. What should the nurse assess first?
A) Pain level
B) Bladder distention
C) Bowel sounds
D) Vital signs
Answer: B
Rationale: A boggy, soft uterus displaced to the right suggests a full bladder
pushing the uterus upward. A full bladder prevents effective contraction and
increases hemorrhage risk.
4. A nurse is caring for a client who is exhibiting signs of postpartum hemorrhage.
The client's blood pressure is 94/58 mm Hg, pulse is 112, and the client has
saturated 1 peri pad in 30 minutes. After massaging the fundus, which action is
most appropriate?
A) Administer oxytocin
B) Call the provider
C) Increase IV fluids
D) Apply oxygen
Answer: A
Rationale: Oxytocin is a uterotonic medication used to manage postpartum
hemorrhage caused by uterine atony. Massaging the fundus and administering
oxytocin are priority interventions.
5. A nurse is monitoring a postpartum client who had a vaginal delivery. Which
finding would indicate uterine atony?
A) Firm fundus at the umbilicus
B) Boggy fundus that does not respond to massage
C) Fundus located below the umbilicus
,D) Moderate lochia rubra
Answer: B
Rationale: Uterine atony presents as a boggy, soft uterus that fails to respond to
massage. This indicates poor uterine muscle tone and is a leading cause of
postpartum hemorrhage.
6. A nurse is assessing a client who is 24 hours postpartum. Which finding is most
important for the nurse to follow up?
A) Temperature of 99.0°F
B) Trickle of bright red blood
C) Fundus firm at the umbilicus
D) Moderate lochia rubra
Answer: B
Rationale: A trickle of bright red blood can indicate a laceration or hematoma,
even with a firm fundus. This requires further assessment and provider notification.
7. A nurse is reinforcing teaching with a client who has mastitis about self-care.
Which instruction indicates correct understanding?
A) Apply cold compress to the breast prior to feeding
B) Breastfeed from the infected side first
C) Stop breastfeeding until infection resolves
D) Apply heat after feeding
Answer: A
Rationale: Applying cold compresses before feeding can help reduce pain and
swelling. The client should continue breastfeeding from the uninfected side first,
then the infected side, and apply heat before feeding to promote milk flow.
8. A nurse is caring for a postpartum client with endometritis. Which nursing
action by a newly hired nurse requires immediate intervention?
A) Administering prescribed antibiotics
B) Encouraging the client to use a douche
C) Monitoring vital signs
D) Assessing fundal tone
Answer: B
Rationale: Douching is contraindicated in endometritis as it can introduce bacteria
and worsen infection. The nurse should intervene immediately to stop this practice.
9. A postpartum client reports painful, swollen breasts on day 3. She is formula
feeding her infant. Which action should the nurse encourage?
A) Pump the breasts to relieve discomfort
, B) Wear a supportive bra
C) Apply warm compresses
D) Massage the breasts
Answer: B
Rationale: For formula-feeding mothers with engorgement, wearing a supportive
bra, applying cold packs, and avoiding breast stimulation are recommended.
Pumping would stimulate more milk production.
10. A nurse is caring for a client following a cesarean delivery. Which intervention
should be recommended for the prevention of venous thrombosis?
A) Administer low molecular weight heparin
B) Encourage early ambulation
C) Apply sequential compression devices
D) All of the above
Answer: D
Rationale: Prevention of venous thrombosis includes early ambulation, sequential
compression devices, and prophylactic anticoagulants such as low molecular
weight heparin.
11. At 24 hours postpartum, which finding is most important for the nurse to
address?
A) A slightly firm uterus
B) Perineal pad saturated every 5 hours
C) Temperature of 99.0°F
D) Total urine voided 1500 mL
Answer: B
Rationale: Saturating a perineal pad every 5 hours indicates heavy bleeding
requiring further assessment. This is a priority finding.
12. A nurse is assessing a postpartum client and notes heavy lochia rubra with
clots. The fundus is firm and midline. What should the nurse suspect?
A) Uterine atony
B) Retained placental fragments
C) Laceration or hematoma
D) Normal finding
Answer: C
Rationale: When the fundus is firm but heavy bleeding persists, the cause may be a
laceration or hematoma. The nurse should assess the perineum and notify the
provider.
