NUR 254 Exams 2 | Galen College |
Complete Maternal & Pediatric
Nursing Exam
Questions and Ansẉers with
rationales
2026\2027 update
51. A nurse is assessing a postpartum client 12 hours after delivery.
The fundus is boggy and deviated to the right of midline. What is
the priority nursing intervention?
A) Administer oxytocin
B) Massage the fundus until firm
C) Assist the client to empty her bladder
D) Assess lochia
AnswerC
Rationale: A deviated fundus (especially to the right) typically
indicates a full bladder, which prevents the uterus from contracting
properly. The first action is to assist the client to empty her bladder.
The fundus can be massged first if it is boggy, but emptying the
bladder addresses the underlying cause.
52. A postpartum client is prescribed methylergonovine
(Methergine). The nurse should hold the medication and notify the
provider if the client has which condition?
,A) Hypertension
B) Hypotension
C) Bradycardia
D) Diabetes
AnswerA
Rationale: Methylergonovine is an ergot alkaloid used to treat
postpartum hemorrhage by causing uterine contraction. It causes
severe vasoconstriction and is contraindicated in clients with
hypertension or pre-eclampsia.
53. A nurse is assessing a postpartum client's lochia on the second
day postpartum. Which finding is expected?
A) Rubra with small clots
B) Serosa with small clots
C) Alba
D) Foul-smelling rubra
AnswerA
Rationale: Lochia rubra is expected for the first 3-4 days
postpartum. Small clots (less than 1 cm) are normal. Foul-smelling
lochia indicates infection. Serosa does not begin until day 3-4.
54. A breastfeeding client calls the clinic reporting engorged,
painful breasts 4 days postpartum. What should the nurse
recommend?
A) Stop breastfeeding until the pain resolves
B) Apply warm compresses and breastfeed frequently
C) Wear a tight-fitting bra continuously
, D) Apply ice packs before feedings
AnswerB
Rationale: Engorgement is best relieved by frequent breastfeeding
or pumping to empty the breasts. Applying warm compresses or
taking a warm shower before feeding helps stimulate milk flow and
reduce swelling.
55. A nurse is caring for a newborn 1 hour after birth. The nurse
observes jitteriness, poor feeding, and a weak cry. Which condition
should the nurse suspect?
A) Hypoglycemia
B) Hyperglycemia
C) Hypocalcemia
D) Sepsis
AnswerA
Rationale: Signs of neonatal hypoglycemia (blood glucose < 40
mg/dL) include jitteriness, poor feeding, lethargy, weak cry, and
seizures. The nurse should immediately check a heel-stick blood
glucose level.
56. A postpartum client reports severe, constant pain in her perineal
area despite taking ibuprofen. The nurse assesses the perineum and
notes a hard, swollen, purple mass on the right labia. What is the
likely diagnosis?
A) Episiotomy dehiscence
B) Vaginal hematoma
C) Thrombosed hemorrhoid
D) Uterine prolapse
Complete Maternal & Pediatric
Nursing Exam
Questions and Ansẉers with
rationales
2026\2027 update
51. A nurse is assessing a postpartum client 12 hours after delivery.
The fundus is boggy and deviated to the right of midline. What is
the priority nursing intervention?
A) Administer oxytocin
B) Massage the fundus until firm
C) Assist the client to empty her bladder
D) Assess lochia
AnswerC
Rationale: A deviated fundus (especially to the right) typically
indicates a full bladder, which prevents the uterus from contracting
properly. The first action is to assist the client to empty her bladder.
The fundus can be massged first if it is boggy, but emptying the
bladder addresses the underlying cause.
52. A postpartum client is prescribed methylergonovine
(Methergine). The nurse should hold the medication and notify the
provider if the client has which condition?
,A) Hypertension
B) Hypotension
C) Bradycardia
D) Diabetes
AnswerA
Rationale: Methylergonovine is an ergot alkaloid used to treat
postpartum hemorrhage by causing uterine contraction. It causes
severe vasoconstriction and is contraindicated in clients with
hypertension or pre-eclampsia.
53. A nurse is assessing a postpartum client's lochia on the second
day postpartum. Which finding is expected?
A) Rubra with small clots
B) Serosa with small clots
C) Alba
D) Foul-smelling rubra
AnswerA
Rationale: Lochia rubra is expected for the first 3-4 days
postpartum. Small clots (less than 1 cm) are normal. Foul-smelling
lochia indicates infection. Serosa does not begin until day 3-4.
54. A breastfeeding client calls the clinic reporting engorged,
painful breasts 4 days postpartum. What should the nurse
recommend?
A) Stop breastfeeding until the pain resolves
B) Apply warm compresses and breastfeed frequently
C) Wear a tight-fitting bra continuously
, D) Apply ice packs before feedings
AnswerB
Rationale: Engorgement is best relieved by frequent breastfeeding
or pumping to empty the breasts. Applying warm compresses or
taking a warm shower before feeding helps stimulate milk flow and
reduce swelling.
55. A nurse is caring for a newborn 1 hour after birth. The nurse
observes jitteriness, poor feeding, and a weak cry. Which condition
should the nurse suspect?
A) Hypoglycemia
B) Hyperglycemia
C) Hypocalcemia
D) Sepsis
AnswerA
Rationale: Signs of neonatal hypoglycemia (blood glucose < 40
mg/dL) include jitteriness, poor feeding, lethargy, weak cry, and
seizures. The nurse should immediately check a heel-stick blood
glucose level.
56. A postpartum client reports severe, constant pain in her perineal
area despite taking ibuprofen. The nurse assesses the perineum and
notes a hard, swollen, purple mass on the right labia. What is the
likely diagnosis?
A) Episiotomy dehiscence
B) Vaginal hematoma
C) Thrombosed hemorrhoid
D) Uterine prolapse
