NU 170 NURSING FUNDAMENTALS EXAM 4 (PDF) | 2026
QUESTIONS AND ANSWERS + RATIONALES | STUDY GUIDE |
100% CORRECT
1. A nurse is completing the initial postpartum assessment for a client who is 2 hours post-
vaginal delivery. The fundus is palpated at the umbilicus, firm, and midline. Which
action should the nurse take?
A) Notify the healthcare provider immediately
B) Document the finding as expected
C) Massage the fundus vigorously to ensure firmness
D) Ask the client to empty her bladder
Correct Answer: Document the finding as expected
Rationale: A firm fundus at the level of the umbilicus and midline at 2 hours postpartum is a
normal expected finding, indicating the uterus is contracting well. No intervention is needed.
Notifying the provider or massaging an already firm fundus is unnecessary unless there is
excessive bleeding or atony.
2. The nurse is assessing a newborn who is 12 hours old. Which finding would the nurse
document as a normal variation for a full-term infant?
A) Generalized cyanosis and pallor
B) Acrocyanosis and a respiratory rate of 55 breaths/min
C) Diminished breath sounds and absent Moro reflex
D) Nasal flaring and substernal retractions
Correct Answer: Acrocyanosis and a respiratory rate of 55 breaths/min
Rationale: Acrocyanosis (bluish discoloration of hands and feet) is a normal finding in newborns
due to immature peripheral circulation. A respiratory rate of 40-60 breaths/min is also normal for
a newborn. Central cyanosis, absent reflexes, or signs of respiratory distress (retractions, nasal
flaring) would be abnormal.
3. A postpartum client is Rh-negative and has given birth to an Rh-positive infant. The
nurse anticipates administering RhoGAM within which time frame?
A) Within 24 hours of delivery
B) Within 72 hours of delivery
C) At the 2-week postpartum visit
D) After 1 month if antibodies develop
Correct Answer: Within 72 hours of delivery
Rationale: RhoGAM should be administered to Rh-negative mothers within 72 hours after
delivery of an Rh-positive infant to prevent maternal alloimmunization. It may also be given
antepartally at 28 weeks. Administering it too late increases the risk of the mother developing
antibodies.
, 4. A newborn is showing signs of respiratory distress, including tachypnea, grunting, and
retractions. The nurse should report which of the following vital signs?
A) Heart rate 140 bpm and respiratory rate 32 breaths/min
B) Heart rate 120 bpm and respiratory rate 55 breaths/min
C) Heart rate 165 bpm and respiratory rate 65 breaths/min
D) Heart rate 110 bpm and respiratory rate 40 breaths/min
Correct Answer: Heart rate 165 bpm and respiratory rate 65 breaths/min
Rationale: Tachycardia (HR >160) and tachypnea (RR >60) in a newborn are signs of respiratory
distress and should be reported. Grunting, retractions, and nasal flaring indicate increased work
of breathing. The other options fall within normal limits for a newborn.
5. A mother who is breastfeeding reports severe breast pain, redness, and a fever. What
condition should the nurse suspect?
A) Engorgement
B) Mastitis
C) Plugged milk duct
D) Thrush
Correct Answer: Mastitis
Rationale: Mastitis is an infection of the breast tissue presenting with symptoms such as breast
pain, redness, swelling, warmth, fever, and flu-like symptoms. Treatment includes antibiotics,
continued breastfeeding, and pain relief. Engorgement and plugged ducts usually occur without
systemic signs of infection.
6. When assessing the newborn's skin, the nurse notes a raised, fluid-filled sac on the scalp
that does not cross the suture line. How should the nurse document this finding?
A) Cephalohematoma
B) Caput succedaneum
C) Molding
D) Fontanelle
Correct Answer: Cephalohematoma
Rationale: Cephalohematoma is a collection of blood between the periosteum and the skull bone,
causing a raised swelling that does not cross suture lines. This differentiates it from caput
succedaneum (edema of the scalp that crosses suture lines). Both are common birth-related
findings.
7. The nurse is teaching a new mother how to care for her newborn's umbilical cord stump.
Which statement by the mother indicates a need for further teaching?
A) "I will fold the diaper below the stump to keep it dry."
B) "I will clean the area with alcohol and water as directed."
C) "I will keep the stump covered with the diaper at all times."
D) "I will watch for signs of redness or drainage around the base."
, Correct Answer: "I will keep the stump covered with the diaper at all times."
Rationale: The umbilical cord stump should be kept dry and exposed to air to promote drying
and separation. Folding the diaper below the stump is the correct technique. Keeping the stump
covered may trap moisture and increase the risk of infection.
8. A postpartum client is experiencing afterpains during breastfeeding. Which explanation
by the nurse is most accurate?
A) "These are contractions of the uterus, which are stimulated by breastfeeding."
B) "The baby is not latching correctly, causing stomach cramping."
C) "This is a sign of a uterine infection and should be reported."
D) "This is normal and will stop after the first feeding."
Correct Answer: "These are contractions of the uterus, which are stimulated by breastfeeding."
Rationale: Afterpains are cramping pains caused by uterine contractions, which are stimulated by
oxytocin release during breastfeeding. These contractions help the uterus return to its pre-
pregnant size (involution). Multiparous women often experience stronger afterpains.
9. The nurse is assisting a new mother with breastfeeding. Which observation indicates a
good latch?
A) The baby's cheeks are dimpled during sucking.
B) The mother hears clicking sounds during feeding.
C) The baby's lips are flanged outward around the areola.
D) The baby's head is turned away from the breast.
Correct Answer: The baby's lips are flanged outward around the areola.
Rationale: A good latch is indicated by the baby having a wide mouth with lips flanged outward
like a "fish mouth." Dimpled cheeks, clicking sounds, and head turning away indicate a poor
latch and ineffective feeding, increasing the risk of nipple trauma and inadequate milk transfer.
10. The nurse is assessing a newborn's reflexes. Which of the following reflexes should be
present at birth but disappear by 4-6 months of age?
A) Babinski reflex
B) Moro reflex
C) Rooting reflex
D) All of the above
Correct Answer: All of the above
Rationale: The Babinski, Moro, and rooting reflexes are primitive reflexes that should be present
at birth and typically disappear within the first 4-6 months of life. Their persistence or absence
beyond the expected age may indicate neurological abnormalities.
11. A nurse is assessing the lochia of a postpartum client on day 2 after delivery. The nurse
notes the discharge is pinkish-brown and serosanguineous. The nurse should document
this finding as:
QUESTIONS AND ANSWERS + RATIONALES | STUDY GUIDE |
100% CORRECT
1. A nurse is completing the initial postpartum assessment for a client who is 2 hours post-
vaginal delivery. The fundus is palpated at the umbilicus, firm, and midline. Which
action should the nurse take?
A) Notify the healthcare provider immediately
B) Document the finding as expected
C) Massage the fundus vigorously to ensure firmness
D) Ask the client to empty her bladder
Correct Answer: Document the finding as expected
Rationale: A firm fundus at the level of the umbilicus and midline at 2 hours postpartum is a
normal expected finding, indicating the uterus is contracting well. No intervention is needed.
Notifying the provider or massaging an already firm fundus is unnecessary unless there is
excessive bleeding or atony.
2. The nurse is assessing a newborn who is 12 hours old. Which finding would the nurse
document as a normal variation for a full-term infant?
A) Generalized cyanosis and pallor
B) Acrocyanosis and a respiratory rate of 55 breaths/min
C) Diminished breath sounds and absent Moro reflex
D) Nasal flaring and substernal retractions
Correct Answer: Acrocyanosis and a respiratory rate of 55 breaths/min
Rationale: Acrocyanosis (bluish discoloration of hands and feet) is a normal finding in newborns
due to immature peripheral circulation. A respiratory rate of 40-60 breaths/min is also normal for
a newborn. Central cyanosis, absent reflexes, or signs of respiratory distress (retractions, nasal
flaring) would be abnormal.
3. A postpartum client is Rh-negative and has given birth to an Rh-positive infant. The
nurse anticipates administering RhoGAM within which time frame?
A) Within 24 hours of delivery
B) Within 72 hours of delivery
C) At the 2-week postpartum visit
D) After 1 month if antibodies develop
Correct Answer: Within 72 hours of delivery
Rationale: RhoGAM should be administered to Rh-negative mothers within 72 hours after
delivery of an Rh-positive infant to prevent maternal alloimmunization. It may also be given
antepartally at 28 weeks. Administering it too late increases the risk of the mother developing
antibodies.
, 4. A newborn is showing signs of respiratory distress, including tachypnea, grunting, and
retractions. The nurse should report which of the following vital signs?
A) Heart rate 140 bpm and respiratory rate 32 breaths/min
B) Heart rate 120 bpm and respiratory rate 55 breaths/min
C) Heart rate 165 bpm and respiratory rate 65 breaths/min
D) Heart rate 110 bpm and respiratory rate 40 breaths/min
Correct Answer: Heart rate 165 bpm and respiratory rate 65 breaths/min
Rationale: Tachycardia (HR >160) and tachypnea (RR >60) in a newborn are signs of respiratory
distress and should be reported. Grunting, retractions, and nasal flaring indicate increased work
of breathing. The other options fall within normal limits for a newborn.
5. A mother who is breastfeeding reports severe breast pain, redness, and a fever. What
condition should the nurse suspect?
A) Engorgement
B) Mastitis
C) Plugged milk duct
D) Thrush
Correct Answer: Mastitis
Rationale: Mastitis is an infection of the breast tissue presenting with symptoms such as breast
pain, redness, swelling, warmth, fever, and flu-like symptoms. Treatment includes antibiotics,
continued breastfeeding, and pain relief. Engorgement and plugged ducts usually occur without
systemic signs of infection.
6. When assessing the newborn's skin, the nurse notes a raised, fluid-filled sac on the scalp
that does not cross the suture line. How should the nurse document this finding?
A) Cephalohematoma
B) Caput succedaneum
C) Molding
D) Fontanelle
Correct Answer: Cephalohematoma
Rationale: Cephalohematoma is a collection of blood between the periosteum and the skull bone,
causing a raised swelling that does not cross suture lines. This differentiates it from caput
succedaneum (edema of the scalp that crosses suture lines). Both are common birth-related
findings.
7. The nurse is teaching a new mother how to care for her newborn's umbilical cord stump.
Which statement by the mother indicates a need for further teaching?
A) "I will fold the diaper below the stump to keep it dry."
B) "I will clean the area with alcohol and water as directed."
C) "I will keep the stump covered with the diaper at all times."
D) "I will watch for signs of redness or drainage around the base."
, Correct Answer: "I will keep the stump covered with the diaper at all times."
Rationale: The umbilical cord stump should be kept dry and exposed to air to promote drying
and separation. Folding the diaper below the stump is the correct technique. Keeping the stump
covered may trap moisture and increase the risk of infection.
8. A postpartum client is experiencing afterpains during breastfeeding. Which explanation
by the nurse is most accurate?
A) "These are contractions of the uterus, which are stimulated by breastfeeding."
B) "The baby is not latching correctly, causing stomach cramping."
C) "This is a sign of a uterine infection and should be reported."
D) "This is normal and will stop after the first feeding."
Correct Answer: "These are contractions of the uterus, which are stimulated by breastfeeding."
Rationale: Afterpains are cramping pains caused by uterine contractions, which are stimulated by
oxytocin release during breastfeeding. These contractions help the uterus return to its pre-
pregnant size (involution). Multiparous women often experience stronger afterpains.
9. The nurse is assisting a new mother with breastfeeding. Which observation indicates a
good latch?
A) The baby's cheeks are dimpled during sucking.
B) The mother hears clicking sounds during feeding.
C) The baby's lips are flanged outward around the areola.
D) The baby's head is turned away from the breast.
Correct Answer: The baby's lips are flanged outward around the areola.
Rationale: A good latch is indicated by the baby having a wide mouth with lips flanged outward
like a "fish mouth." Dimpled cheeks, clicking sounds, and head turning away indicate a poor
latch and ineffective feeding, increasing the risk of nipple trauma and inadequate milk transfer.
10. The nurse is assessing a newborn's reflexes. Which of the following reflexes should be
present at birth but disappear by 4-6 months of age?
A) Babinski reflex
B) Moro reflex
C) Rooting reflex
D) All of the above
Correct Answer: All of the above
Rationale: The Babinski, Moro, and rooting reflexes are primitive reflexes that should be present
at birth and typically disappear within the first 4-6 months of life. Their persistence or absence
beyond the expected age may indicate neurological abnormalities.
11. A nurse is assessing the lochia of a postpartum client on day 2 after delivery. The nurse
notes the discharge is pinkish-brown and serosanguineous. The nurse should document
this finding as:
