NUR 254 EXAM 2 300 ACTUAL QUESTIONS AND
CORRECT ANSWERS WITH RATIONALE LATEST
UPDATE ALREADY GRADED A+
This comprehensive set of 300 multiple-choice questions covers the essential content for
NUR 254 Exam 2, focusing on maternal-newborn nursing care. Topics include postpartum
maternal assessment using the BUBBLE-HE framework, lochia progression, uterine
involution, and complications such as postpartum hemorrhage, endometritis, mastitis, and
thrombophlebitis. Newborn content includes APGAR scoring, transitional periods,
thermoregulation, hypoglycemia, hyperbilirubinemia, respiratory distress, congenital
anomalies, and safe sleep practices. Each question includes a correct answer and detailed
rationale explaining the underlying physiological concepts, nursing interventions, and
clinical reasoning. This comprehensive review ensures thorough preparation without
repetition of concepts or scenarios.
1. A nurse is assessing a newborn's respiratory status. Which finding would be considered
normal?
A) Respiratory rate of 20 breaths per minute
B) Respiratory rate of 45 breaths per minute with irregular rhythm
C) Respiratory rate of 65 breaths per minute with grunting
D) Respiratory rate of 15 breaths per minute with nasal flaring
Answer: B
Rationale: Newborn respiratory rates range from 30-60 breaths per minute and are
characteristically irregular with short pauses. Grunting and nasal flaring are signs of respiratory
distress rather than normal findings. A rate of 20 is too slow, and 65 with grunting indicates
distress requiring intervention .
2. A postpartum client asks the nurse about the different types of lochia. The nurse correctly
explains that lochia rubra is:
A) Pinkish-brown discharge occurring 4-10 days postpartum
B) Bright red discharge occurring 1-3 days postpartum
C) Whitish-yellow discharge occurring 10-14 days postpartum
D) Dark red discharge occurring 2-4 weeks postpartum
Answer: B
Rationale: Lochia rubra is bright red and lasts for the first 1-3 days postpartum. Lochia serosa is
pinkish-brown from 4-10 days, and lochia alba is whitish-yellow from 10-14 days. This
represents the normal progression of postpartum uterine discharge .
3. During the immediate postpartum assessment, the nurse palpates the fundus 2 cm above the
umbilicus and deviated to the right. Which action should the nurse take first?
A) Document the finding as normal
B) Massage the fundus and assist the client to void
C) Notify the healthcare provider immediately
,D) Administer oxytocin as prescribed
Answer: B
Rationale: A displaced fundus often indicates a full bladder, which can prevent uterine
contraction and increase bleeding risk. The nurse should assist the client to void and then
reassess fundal position. A boggy uterus not at the midline suggests possible hemorrhage, but the
first action is to address bladder distension .
4. A postpartum client has a temperature of 100.6°F. The most appropriate nursing action is:
A) Document the finding as normal postpartum temperature elevation
B) Assess for other signs of infection and notify the provider
C) Administer acetaminophen as prescribed
D) Encourage increased oral fluid intake
Answer: B
Rationale: A temperature above 100.4°F during the postpartum period is considered elevated and
may indicate infection. The nurse should assess for other signs such as breast engorgement,
uterine tenderness, foul-smelling lochia, or urinary tract symptoms. While slight temperature
elevation can occur with dehydration, this degree warrants further investigation .
5. A nurse is assessing a newborn one minute after birth. Which finding would receive the
highest APGAR score?
A) Heart rate of 110 beats per minute, irregular respirations, and acrocyanosis
B) Heart rate of 160 beats per minute, strong cry, and pink color
C) Heart rate of 90 beats per minute, slow respirations, and blue extremities
D) Heart rate of 120 beats per minute, weak cry, and pink body
Answer: B
Rationale: An APGAR score evaluates heart rate, respiratory effort, muscle tone, reflex
irritability, and color. A strong cry indicates good respiratory effort, and pink color (not just
acrocyanosis) receives the highest score. A score of 7 or above is considered normal, and this
baby would likely receive a score of 9 or 10 .
6. The nurse is providing discharge teaching to new parents about sudden infant death syndrome
(SIDS) prevention. Which instruction is most important?
A) Place the infant in a side-lying position for sleep
B) Place the infant on the back for sleep
C) Use a soft mattress and thick blanket for comfort
D) Keep the room temperature warm
Answer: B
Rationale: Placing infants on their back for sleep (supine position) is the single most important
intervention to reduce SIDS risk. Additional recommendations include using a firm mattress with
no loose bedding, avoiding overheating, and ensuring a smoke-free environment .
7. A postpartum client is exhibiting signs of "taking in" according to Rubin's maternal role
attainment theory. Which behavior would the nurse expect?
A) Independently caring for the newborn's needs
B) Delegating infant care to family members
C) Repeating details of the birth experience
,D) Expressing confidence in parenting abilities
Answer: C
Rationale: Rubin's phases of maternal role attainment include: Phase 1 - Taking In (first 1-2
days), where the mother focuses on herself and repeats the details of the birth experience. Phase
2 - Taking Hold occurs when the mother becomes actively involved in infant care. Phase 3 -
Letting Go involves integrating the maternal role .
8. A newborn has been administered vitamin K prophylaxis. The nurse explains that the purpose
is to:
A) Prevent respiratory distress syndrome
B) Prevent hemorrhagic complications
C) Prevent jaundice
D) Prevent infection
Answer: B
Rationale: Vitamin K is administered prophylactically to newborns at birth because they have
low levels of this fat-soluble vitamin and their intestinal flora is not yet established to produce it.
Vitamin K promotes blood clotting and prevents hemorrhagic disease of the newborn .
9. A postpartum client with asthma is prescribed Hemabate for postpartum hemorrhage. The
nurse should question this order because:
A) Hemabate should not be used in clients with asthma
B) Hemabate should be used only for late hemorrhage
C) Hemabate is contraindicated in postpartum clients
D) Hemabate must be given intravenously
Answer: A
Rationale: Hemabate (carboprost tromethamine) is a prostaglandin used to treat postpartum
hemorrhage. It is contraindicated in clients with asthma because it can cause bronchospasm.
Alternative agents such as oxytocin or misoprostol should be considered .
10. When assessing a postpartum client's lochia, the nurse notes a foul odor and continued flow.
This finding is most consistent with:
A) Normal lochia progression
B) Endometritis
C) Retained placental fragments
D) Hematoma formation
Answer: B
Rationale: Foul-smelling lochia accompanied by continued flow is a classic sign of endometritis,
an infection of the uterine lining. Other signs include fever, uterine tenderness, and pelvic pain.
Retained fragments may cause heavy bleeding, and hematomas cause localized pain and swelling
.
11. A nurse is assessing a newborn's vision. Which finding indicates normal visual development?
A) The newborn can see clearly at 3 feet
B) The newborn tracks objects at 6-7 inches distance
C) The newborn demonstrates color vision at birth
D) The newborn has perfect vision 20/20
, Answer: B
Rationale: Newborns have the clearest vision at 6-7 inches, which is approximately the distance
to the parent's face during feeding. They can see up to 2.5 feet and begin to see color around 2
months of age .
12. A postpartum client is suspected of having a hematoma. Which assessment finding would the
nurse expect?
A) Foul-smelling lochia and fever
B) Perineal discoloration and severe pain
C) Calf pain and swelling
D) Breast redness and tenderness
Answer: B
Rationale: Hematomas present with perineal discoloration (bruising), severe perineal pain,
edema, and rectal pressure. They may cause bleeding as well. Foul lochia with fever suggests
infection, calf pain suggests thrombophlebitis, and breast redness suggests mastitis .
13. The nurse is performing a newborn assessment using the BUBBLE-HE framework. This
acronym stands for:
A) Breasts, Uterus, Bladder, Bowels, Lochia, Episiotomy, Hemorrhoids, Emotional status
B) Breathing, Urine output, Blood pressure, Bowels, Lab work, EKG
C) Body temperature, Urinalysis, Breastfeeding, Birth weight, Laboratory results, Electrolytes
D) Blood sugar, Urine, Bruises, Breathing, Lungs, Energy
Answer: A
Rationale: BUBBLE-HE is a postpartum assessment framework covering: Breasts, Uterus,
Bladder, Bowels, Lochia, Episiotomy/perineum, Hemorrhoids, and Emotional status. This
comprehensive approach ensures all aspects of maternal recovery are assessed .
14. A newborn is noted to have a heart rate of 170 beats per minute during the first period of
reactivity. The nurse should:
A) Notify the healthcare provider immediately
B) Document this as a normal finding
C) Perform a full cardiac assessment
D) Reassess the newborn in 30 minutes
Answer: B
Rationale: During the first period of reactivity, which occurs 15-30 minutes after birth, the
newborn's heart rate can be 160-180 beats per minute. This is a normal finding. The newborn
then enters a period of decreased responsiveness lasting 60-100 minutes before the second period
of reactivity .
15. A postpartum client reports calf pain and leg tenderness. The nurse notes redness and
swelling. Which condition should the nurse suspect?
A) Mastitis
B) Endometritis
C) Thrombophlebitis
D) Hematoma
Answer: C
CORRECT ANSWERS WITH RATIONALE LATEST
UPDATE ALREADY GRADED A+
This comprehensive set of 300 multiple-choice questions covers the essential content for
NUR 254 Exam 2, focusing on maternal-newborn nursing care. Topics include postpartum
maternal assessment using the BUBBLE-HE framework, lochia progression, uterine
involution, and complications such as postpartum hemorrhage, endometritis, mastitis, and
thrombophlebitis. Newborn content includes APGAR scoring, transitional periods,
thermoregulation, hypoglycemia, hyperbilirubinemia, respiratory distress, congenital
anomalies, and safe sleep practices. Each question includes a correct answer and detailed
rationale explaining the underlying physiological concepts, nursing interventions, and
clinical reasoning. This comprehensive review ensures thorough preparation without
repetition of concepts or scenarios.
1. A nurse is assessing a newborn's respiratory status. Which finding would be considered
normal?
A) Respiratory rate of 20 breaths per minute
B) Respiratory rate of 45 breaths per minute with irregular rhythm
C) Respiratory rate of 65 breaths per minute with grunting
D) Respiratory rate of 15 breaths per minute with nasal flaring
Answer: B
Rationale: Newborn respiratory rates range from 30-60 breaths per minute and are
characteristically irregular with short pauses. Grunting and nasal flaring are signs of respiratory
distress rather than normal findings. A rate of 20 is too slow, and 65 with grunting indicates
distress requiring intervention .
2. A postpartum client asks the nurse about the different types of lochia. The nurse correctly
explains that lochia rubra is:
A) Pinkish-brown discharge occurring 4-10 days postpartum
B) Bright red discharge occurring 1-3 days postpartum
C) Whitish-yellow discharge occurring 10-14 days postpartum
D) Dark red discharge occurring 2-4 weeks postpartum
Answer: B
Rationale: Lochia rubra is bright red and lasts for the first 1-3 days postpartum. Lochia serosa is
pinkish-brown from 4-10 days, and lochia alba is whitish-yellow from 10-14 days. This
represents the normal progression of postpartum uterine discharge .
3. During the immediate postpartum assessment, the nurse palpates the fundus 2 cm above the
umbilicus and deviated to the right. Which action should the nurse take first?
A) Document the finding as normal
B) Massage the fundus and assist the client to void
C) Notify the healthcare provider immediately
,D) Administer oxytocin as prescribed
Answer: B
Rationale: A displaced fundus often indicates a full bladder, which can prevent uterine
contraction and increase bleeding risk. The nurse should assist the client to void and then
reassess fundal position. A boggy uterus not at the midline suggests possible hemorrhage, but the
first action is to address bladder distension .
4. A postpartum client has a temperature of 100.6°F. The most appropriate nursing action is:
A) Document the finding as normal postpartum temperature elevation
B) Assess for other signs of infection and notify the provider
C) Administer acetaminophen as prescribed
D) Encourage increased oral fluid intake
Answer: B
Rationale: A temperature above 100.4°F during the postpartum period is considered elevated and
may indicate infection. The nurse should assess for other signs such as breast engorgement,
uterine tenderness, foul-smelling lochia, or urinary tract symptoms. While slight temperature
elevation can occur with dehydration, this degree warrants further investigation .
5. A nurse is assessing a newborn one minute after birth. Which finding would receive the
highest APGAR score?
A) Heart rate of 110 beats per minute, irregular respirations, and acrocyanosis
B) Heart rate of 160 beats per minute, strong cry, and pink color
C) Heart rate of 90 beats per minute, slow respirations, and blue extremities
D) Heart rate of 120 beats per minute, weak cry, and pink body
Answer: B
Rationale: An APGAR score evaluates heart rate, respiratory effort, muscle tone, reflex
irritability, and color. A strong cry indicates good respiratory effort, and pink color (not just
acrocyanosis) receives the highest score. A score of 7 or above is considered normal, and this
baby would likely receive a score of 9 or 10 .
6. The nurse is providing discharge teaching to new parents about sudden infant death syndrome
(SIDS) prevention. Which instruction is most important?
A) Place the infant in a side-lying position for sleep
B) Place the infant on the back for sleep
C) Use a soft mattress and thick blanket for comfort
D) Keep the room temperature warm
Answer: B
Rationale: Placing infants on their back for sleep (supine position) is the single most important
intervention to reduce SIDS risk. Additional recommendations include using a firm mattress with
no loose bedding, avoiding overheating, and ensuring a smoke-free environment .
7. A postpartum client is exhibiting signs of "taking in" according to Rubin's maternal role
attainment theory. Which behavior would the nurse expect?
A) Independently caring for the newborn's needs
B) Delegating infant care to family members
C) Repeating details of the birth experience
,D) Expressing confidence in parenting abilities
Answer: C
Rationale: Rubin's phases of maternal role attainment include: Phase 1 - Taking In (first 1-2
days), where the mother focuses on herself and repeats the details of the birth experience. Phase
2 - Taking Hold occurs when the mother becomes actively involved in infant care. Phase 3 -
Letting Go involves integrating the maternal role .
8. A newborn has been administered vitamin K prophylaxis. The nurse explains that the purpose
is to:
A) Prevent respiratory distress syndrome
B) Prevent hemorrhagic complications
C) Prevent jaundice
D) Prevent infection
Answer: B
Rationale: Vitamin K is administered prophylactically to newborns at birth because they have
low levels of this fat-soluble vitamin and their intestinal flora is not yet established to produce it.
Vitamin K promotes blood clotting and prevents hemorrhagic disease of the newborn .
9. A postpartum client with asthma is prescribed Hemabate for postpartum hemorrhage. The
nurse should question this order because:
A) Hemabate should not be used in clients with asthma
B) Hemabate should be used only for late hemorrhage
C) Hemabate is contraindicated in postpartum clients
D) Hemabate must be given intravenously
Answer: A
Rationale: Hemabate (carboprost tromethamine) is a prostaglandin used to treat postpartum
hemorrhage. It is contraindicated in clients with asthma because it can cause bronchospasm.
Alternative agents such as oxytocin or misoprostol should be considered .
10. When assessing a postpartum client's lochia, the nurse notes a foul odor and continued flow.
This finding is most consistent with:
A) Normal lochia progression
B) Endometritis
C) Retained placental fragments
D) Hematoma formation
Answer: B
Rationale: Foul-smelling lochia accompanied by continued flow is a classic sign of endometritis,
an infection of the uterine lining. Other signs include fever, uterine tenderness, and pelvic pain.
Retained fragments may cause heavy bleeding, and hematomas cause localized pain and swelling
.
11. A nurse is assessing a newborn's vision. Which finding indicates normal visual development?
A) The newborn can see clearly at 3 feet
B) The newborn tracks objects at 6-7 inches distance
C) The newborn demonstrates color vision at birth
D) The newborn has perfect vision 20/20
, Answer: B
Rationale: Newborns have the clearest vision at 6-7 inches, which is approximately the distance
to the parent's face during feeding. They can see up to 2.5 feet and begin to see color around 2
months of age .
12. A postpartum client is suspected of having a hematoma. Which assessment finding would the
nurse expect?
A) Foul-smelling lochia and fever
B) Perineal discoloration and severe pain
C) Calf pain and swelling
D) Breast redness and tenderness
Answer: B
Rationale: Hematomas present with perineal discoloration (bruising), severe perineal pain,
edema, and rectal pressure. They may cause bleeding as well. Foul lochia with fever suggests
infection, calf pain suggests thrombophlebitis, and breast redness suggests mastitis .
13. The nurse is performing a newborn assessment using the BUBBLE-HE framework. This
acronym stands for:
A) Breasts, Uterus, Bladder, Bowels, Lochia, Episiotomy, Hemorrhoids, Emotional status
B) Breathing, Urine output, Blood pressure, Bowels, Lab work, EKG
C) Body temperature, Urinalysis, Breastfeeding, Birth weight, Laboratory results, Electrolytes
D) Blood sugar, Urine, Bruises, Breathing, Lungs, Energy
Answer: A
Rationale: BUBBLE-HE is a postpartum assessment framework covering: Breasts, Uterus,
Bladder, Bowels, Lochia, Episiotomy/perineum, Hemorrhoids, and Emotional status. This
comprehensive approach ensures all aspects of maternal recovery are assessed .
14. A newborn is noted to have a heart rate of 170 beats per minute during the first period of
reactivity. The nurse should:
A) Notify the healthcare provider immediately
B) Document this as a normal finding
C) Perform a full cardiac assessment
D) Reassess the newborn in 30 minutes
Answer: B
Rationale: During the first period of reactivity, which occurs 15-30 minutes after birth, the
newborn's heart rate can be 160-180 beats per minute. This is a normal finding. The newborn
then enters a period of decreased responsiveness lasting 60-100 minutes before the second period
of reactivity .
15. A postpartum client reports calf pain and leg tenderness. The nurse notes redness and
swelling. Which condition should the nurse suspect?
A) Mastitis
B) Endometritis
C) Thrombophlebitis
D) Hematoma
Answer: C
