NUR 230 Maternal Exam 2 | Galen College of
Nursings
1. The nurse is assessing physiological changes in a newborn. Which of the following is the priority
concern?
A. Successful feeding
B. Thermoregulation
C. Extra-uterine circulatory transition
D. Spontaneous respirations
Correct Answer: B
Rationale: Newborns are at high risk for cold stress due to large body surface area, thin skin, limited
subcutaneous fat, and immature thermoregulation. Cold stress increases oxygen consumption and can
lead to hypoglycemia and metabolic acidosis. Maintaining a neutral thermal environment is a top
priority immediately after birth (AAP Newborn Care Guidelines).
2. The nurse is caring for a newborn immediately after birth. Which intervention is most important to
prevent heat loss?
A. Place a hat on the infant’s head
B. Utilize a clear plastic wrap or radiant warmer
C. Bathe the infant within the first 30 minutes
D. Encourage skin-to-skin contact only after the bath
Correct Answer: B
Rationale: Evaporative heat loss is rapid in the first minutes of life. Using plastic wrap or a radiant
warmer immediately after drying the infant is the most effective initial intervention to prevent
hypothermia (AWHONN and AAP standards).
3. A newborn has an axillary temperature of 36.2°C (97.2°F) one hour after birth. The nurse recognizes
this as:
A. A normal variation
B. Cold stress requiring immediate intervention
C. Expected due to maternal medications
D. An early sign of sepsis
Correct Answer: B
Rationale: Normal newborn temperature is 36.5–37.5°C. A temperature below 36.5°C indicates cold
stress, which must be treated promptly to prevent increased metabolic demand, hypoglycemia, and
respiratory distress.
4. A full-term newborn is jittery with a blood glucose of 38 mg/dL at 2 hours of age. The nurse’s first
action is to:
A. Administer glucagon IM
B. Initiate skin-to-skin contact and encourage breastfeeding
C. Start an IV dextrose bolus
D. Notify the provider for insulin
, Correct Answer: B
Rationale: Early mild hypoglycemia is best treated with early feeding and skin-to-skin contact, which
promotes thermoregulation and glucose stabilization (AAP Clinical Practice Guideline on Neonatal
Hypoglycemia, 2022/2025).
5. At 1 minute of life, a newborn is pink, has a weak cry, heart rate 110 bpm, some flexion of
extremities, and grimaces to stimulation. The Apgar score is:
A. 5
B. 7
C. 8
D. 9
Correct Answer: B
Rationale: Score breakdown: Heart rate (2), Respiratory effort (1), Muscle tone (1), Reflex irritability
(1), Color (2) = 7. A score of 7–10 at 1 minute is considered reassuring.
6. A postpartum client’s fundus is firm, midline, and 2 fingerbreadths above the umbilicus 6 hours after
delivery. The nurse should:
A. Document as normal
B. Assist the client to void and recheck the fundus
C. Notify the provider immediately
D. Administer methylergonovine
Correct Answer: B
Rationale: A full bladder commonly displaces the uterus upward. Voiding usually allows the fundus to
descend. This is part of standard BUBBLE-HE postpartum assessment.
7. The nurse notes a boggy uterus and heavy lochia with clots 2 hours postpartum. The first nursing
action is:
A. Perform fundal massage
B. Insert a Foley catheter
C. Administer oxytocin IV immediately
D. Prepare for blood transfusion
Correct Answer: A
Rationale: Uterine atony is the leading cause of early postpartum hemorrhage. Firm fundal massage
stimulates uterine contraction and is always the initial intervention (ACOG Postpartum Hemorrhage
Guidelines).
8. A breastfeeding mother develops unilateral breast redness, warmth, and flu-like symptoms on
postpartum day 4. The nurse suspects:
A. Normal engorgement
B. Mastitis
C. Plugged milk duct
D. Breast abscess
Correct Answer: B
Nursings
1. The nurse is assessing physiological changes in a newborn. Which of the following is the priority
concern?
A. Successful feeding
B. Thermoregulation
C. Extra-uterine circulatory transition
D. Spontaneous respirations
Correct Answer: B
Rationale: Newborns are at high risk for cold stress due to large body surface area, thin skin, limited
subcutaneous fat, and immature thermoregulation. Cold stress increases oxygen consumption and can
lead to hypoglycemia and metabolic acidosis. Maintaining a neutral thermal environment is a top
priority immediately after birth (AAP Newborn Care Guidelines).
2. The nurse is caring for a newborn immediately after birth. Which intervention is most important to
prevent heat loss?
A. Place a hat on the infant’s head
B. Utilize a clear plastic wrap or radiant warmer
C. Bathe the infant within the first 30 minutes
D. Encourage skin-to-skin contact only after the bath
Correct Answer: B
Rationale: Evaporative heat loss is rapid in the first minutes of life. Using plastic wrap or a radiant
warmer immediately after drying the infant is the most effective initial intervention to prevent
hypothermia (AWHONN and AAP standards).
3. A newborn has an axillary temperature of 36.2°C (97.2°F) one hour after birth. The nurse recognizes
this as:
A. A normal variation
B. Cold stress requiring immediate intervention
C. Expected due to maternal medications
D. An early sign of sepsis
Correct Answer: B
Rationale: Normal newborn temperature is 36.5–37.5°C. A temperature below 36.5°C indicates cold
stress, which must be treated promptly to prevent increased metabolic demand, hypoglycemia, and
respiratory distress.
4. A full-term newborn is jittery with a blood glucose of 38 mg/dL at 2 hours of age. The nurse’s first
action is to:
A. Administer glucagon IM
B. Initiate skin-to-skin contact and encourage breastfeeding
C. Start an IV dextrose bolus
D. Notify the provider for insulin
, Correct Answer: B
Rationale: Early mild hypoglycemia is best treated with early feeding and skin-to-skin contact, which
promotes thermoregulation and glucose stabilization (AAP Clinical Practice Guideline on Neonatal
Hypoglycemia, 2022/2025).
5. At 1 minute of life, a newborn is pink, has a weak cry, heart rate 110 bpm, some flexion of
extremities, and grimaces to stimulation. The Apgar score is:
A. 5
B. 7
C. 8
D. 9
Correct Answer: B
Rationale: Score breakdown: Heart rate (2), Respiratory effort (1), Muscle tone (1), Reflex irritability
(1), Color (2) = 7. A score of 7–10 at 1 minute is considered reassuring.
6. A postpartum client’s fundus is firm, midline, and 2 fingerbreadths above the umbilicus 6 hours after
delivery. The nurse should:
A. Document as normal
B. Assist the client to void and recheck the fundus
C. Notify the provider immediately
D. Administer methylergonovine
Correct Answer: B
Rationale: A full bladder commonly displaces the uterus upward. Voiding usually allows the fundus to
descend. This is part of standard BUBBLE-HE postpartum assessment.
7. The nurse notes a boggy uterus and heavy lochia with clots 2 hours postpartum. The first nursing
action is:
A. Perform fundal massage
B. Insert a Foley catheter
C. Administer oxytocin IV immediately
D. Prepare for blood transfusion
Correct Answer: A
Rationale: Uterine atony is the leading cause of early postpartum hemorrhage. Firm fundal massage
stimulates uterine contraction and is always the initial intervention (ACOG Postpartum Hemorrhage
Guidelines).
8. A breastfeeding mother develops unilateral breast redness, warmth, and flu-like symptoms on
postpartum day 4. The nurse suspects:
A. Normal engorgement
B. Mastitis
C. Plugged milk duct
D. Breast abscess
Correct Answer: B
