Rasmussen University NUR 2513 Exam 2 (pdf) | 2026/2027 |
Maternal-Child Q&A | Nursing
1. A nurse is assessing a postpartum client who is 24 hours post-delivery.
Which finding indicates normal involution of the uterus?
A) The fundus is palpated at the level of the umbilicus
B) The fundus is palpated two fingerbreadths below the umbilicus
C) The fundus is palpated two fingerbreadths above the umbilicus
D) The fundus is not palpable
Correct Answer: The fundus is palpated one fingerbreadth below the
umbilicus
Rationale: By 24 hours postpartum, the fundus should be at the level of the
umbilicus. It descends approximately one fingerbreadth (1 cm) per day after
delivery. By day 10, it should no longer be palpable. A fundus above the
umbilicus may indicate bladder distention or retained products of conception.
2. A nurse is evaluating the lochia of a client who is 2 days postpartum.
Which finding would the nurse document as normal?
A) Scant amount of serosanguineous drainage
B) Moderate amount of bright red drainage
C) Scant amount of pinkish-brown drainage
D) Moderate amount of creamy white drainage
Correct Answer: Moderate amount of bright red drainage
Rationale: Lochia rubra is the first stage of postpartum bleeding, lasting for
the first 1-3 days after delivery. It is characterized by a moderate to heavy
flow of bright red blood. Serosanguineous (pinkish-brown) drainage is lochia
,serosa, which typically appears around days 4-10. Creamy white drainage is
lochia alba, which appears around days 11-14.
3. A nurse is assessing a newborn's Apgar score at 1 minute of life. The
newborn has a heart rate of 120 bpm, a strong cry, active motion, cries in
response to stimulation, and pink body with blue extremities. What Apgar
score should the nurse assign?
A) 7
B) 8
C) 9
D) 10
Correct Answer: 9
Rationale: The Apgar score assesses five categories: heart rate (2 points for
>100 bpm), respiratory effort (2 points for a strong cry), muscle tone (2
points for active motion), reflex irritability (2 points for crying in response to
stimulation), and color (1 point for pink body with blue extremities -
acrocyanosis). Total = 2+2+2+2+1 = 9. A score of 10 would require a
completely pink body.
4. A nurse is preparing to administer vitamin K to a newborn. Which site is
most appropriate for the injection?
A) Deltoid muscle
B) Vastus lateralis muscle
C) Ventrogluteal muscle
D) Subcutaneous tissue of the abdomen
Correct Answer: Vastus lateralis muscle
,Rationale: Vitamin K is administered intramuscularly to newborns at the
vastus lateralis muscle (mid-thigh) to prevent hemorrhagic disease of the
newborn. The deltoid and ventrogluteal muscles are not used in newborns
due to their small size and the risk of injury.
5. A postpartum client is being evaluated for risk of venous
thromboembolism (VTE). Which assessment findings should the nurse
include? (Select all that apply)
A) Observe distal upper extremities for swelling/edema
B) Observe lower extremities for symmetry
C) Assess for uterine cramping
D) Observe respiratory rate and effort
E) Auscultate lung sounds
Correct Answer: Observe lower extremities for symmetry, Observe
respiratory rate and effort, Auscultate lung sounds
Rationale: Women are hypercoagulable during the third trimester of
pregnancy and the postpartum period, increasing their risk for VTE.
Assessment should include observing lower extremities for symmetry
(asymmetric swelling may indicate a DVT), observing respiratory rate and
effort, and auscultating lung sounds (tachypnea, crackles, or diminished
breath sounds may indicate a pulmonary embolism).
6. A new mother asks the nurse when she can start breastfeeding her
newborn. What is the nurse's best response?
A) "Once the infant has had his first feeding of formula."
B) "Immediately after birth."
C) "In 24 hours after your infant is given water."
D) "After the infant is allowed to rest."
, Correct Answer: "Immediately after birth."
Rationale: Breastfeeding should be initiated as soon as possible after birth,
ideally within the first hour. Early skin-to-skin contact and breastfeeding
promote maternal-infant bonding, stimulate milk production, and provide the
newborn with colostrum.
7. A nurse is caring for a 4-year-old child. Which of the following is an
expected cognitive development for a preschool-aged child?
A) Describing manifestations of illness
B) Understanding cause of illness
C) Relating fears to magical thinking
D) Awareness of body function
Correct Answer: Relating fears to magical thinking
Rationale: Preschool-aged children (ages 3-5) often engage in magical
thinking, believing that their thoughts or wishes can cause events. They may
attribute illness to something they did wrong or believe in imaginary causes.
Understanding the cause of illness and describing manifestations are not
typical for this age group.
8. A nurse is assessing a newborn for developmental dysplasia of the hip
(DDH). Which finding indicates hip subluxation?
A) Crying on straightening of the right leg
B) Inward rotation of the right foot
C) Inability of the right hip to abduct
D) Drawing of the legs underneath while prone
Correct Answer: Inability of the right hip to abduct
Maternal-Child Q&A | Nursing
1. A nurse is assessing a postpartum client who is 24 hours post-delivery.
Which finding indicates normal involution of the uterus?
A) The fundus is palpated at the level of the umbilicus
B) The fundus is palpated two fingerbreadths below the umbilicus
C) The fundus is palpated two fingerbreadths above the umbilicus
D) The fundus is not palpable
Correct Answer: The fundus is palpated one fingerbreadth below the
umbilicus
Rationale: By 24 hours postpartum, the fundus should be at the level of the
umbilicus. It descends approximately one fingerbreadth (1 cm) per day after
delivery. By day 10, it should no longer be palpable. A fundus above the
umbilicus may indicate bladder distention or retained products of conception.
2. A nurse is evaluating the lochia of a client who is 2 days postpartum.
Which finding would the nurse document as normal?
A) Scant amount of serosanguineous drainage
B) Moderate amount of bright red drainage
C) Scant amount of pinkish-brown drainage
D) Moderate amount of creamy white drainage
Correct Answer: Moderate amount of bright red drainage
Rationale: Lochia rubra is the first stage of postpartum bleeding, lasting for
the first 1-3 days after delivery. It is characterized by a moderate to heavy
flow of bright red blood. Serosanguineous (pinkish-brown) drainage is lochia
,serosa, which typically appears around days 4-10. Creamy white drainage is
lochia alba, which appears around days 11-14.
3. A nurse is assessing a newborn's Apgar score at 1 minute of life. The
newborn has a heart rate of 120 bpm, a strong cry, active motion, cries in
response to stimulation, and pink body with blue extremities. What Apgar
score should the nurse assign?
A) 7
B) 8
C) 9
D) 10
Correct Answer: 9
Rationale: The Apgar score assesses five categories: heart rate (2 points for
>100 bpm), respiratory effort (2 points for a strong cry), muscle tone (2
points for active motion), reflex irritability (2 points for crying in response to
stimulation), and color (1 point for pink body with blue extremities -
acrocyanosis). Total = 2+2+2+2+1 = 9. A score of 10 would require a
completely pink body.
4. A nurse is preparing to administer vitamin K to a newborn. Which site is
most appropriate for the injection?
A) Deltoid muscle
B) Vastus lateralis muscle
C) Ventrogluteal muscle
D) Subcutaneous tissue of the abdomen
Correct Answer: Vastus lateralis muscle
,Rationale: Vitamin K is administered intramuscularly to newborns at the
vastus lateralis muscle (mid-thigh) to prevent hemorrhagic disease of the
newborn. The deltoid and ventrogluteal muscles are not used in newborns
due to their small size and the risk of injury.
5. A postpartum client is being evaluated for risk of venous
thromboembolism (VTE). Which assessment findings should the nurse
include? (Select all that apply)
A) Observe distal upper extremities for swelling/edema
B) Observe lower extremities for symmetry
C) Assess for uterine cramping
D) Observe respiratory rate and effort
E) Auscultate lung sounds
Correct Answer: Observe lower extremities for symmetry, Observe
respiratory rate and effort, Auscultate lung sounds
Rationale: Women are hypercoagulable during the third trimester of
pregnancy and the postpartum period, increasing their risk for VTE.
Assessment should include observing lower extremities for symmetry
(asymmetric swelling may indicate a DVT), observing respiratory rate and
effort, and auscultating lung sounds (tachypnea, crackles, or diminished
breath sounds may indicate a pulmonary embolism).
6. A new mother asks the nurse when she can start breastfeeding her
newborn. What is the nurse's best response?
A) "Once the infant has had his first feeding of formula."
B) "Immediately after birth."
C) "In 24 hours after your infant is given water."
D) "After the infant is allowed to rest."
, Correct Answer: "Immediately after birth."
Rationale: Breastfeeding should be initiated as soon as possible after birth,
ideally within the first hour. Early skin-to-skin contact and breastfeeding
promote maternal-infant bonding, stimulate milk production, and provide the
newborn with colostrum.
7. A nurse is caring for a 4-year-old child. Which of the following is an
expected cognitive development for a preschool-aged child?
A) Describing manifestations of illness
B) Understanding cause of illness
C) Relating fears to magical thinking
D) Awareness of body function
Correct Answer: Relating fears to magical thinking
Rationale: Preschool-aged children (ages 3-5) often engage in magical
thinking, believing that their thoughts or wishes can cause events. They may
attribute illness to something they did wrong or believe in imaginary causes.
Understanding the cause of illness and describing manifestations are not
typical for this age group.
8. A nurse is assessing a newborn for developmental dysplasia of the hip
(DDH). Which finding indicates hip subluxation?
A) Crying on straightening of the right leg
B) Inward rotation of the right foot
C) Inability of the right hip to abduct
D) Drawing of the legs underneath while prone
Correct Answer: Inability of the right hip to abduct
