NUR 231 Exam 3 – Maternal Nursing | Galen College
(2026) | Advanced/Hard Difficulty | Professional Level |
100% Pass Guaranteed | Graded A+
1. A 28-year-old patient who is G2P2 gave birth to a healthy 7 lb 8 oz infant via vaginal
delivery 2 hours ago. The nurse notes that her fundus is firm, midline, and at the level of the
umbilicus. The patient has moderate lochia rubra with a few small clots. Which nursing action
is most appropriate?
A. Massage the fundus vigorously until it becomes boggy
B. Continue to monitor the patient's uterine tone and lochia
C. Notify the healthcare provider of an abnormal assessment
D. Administer oxytocin 10 units IM
Correct Answer: B
Explanation: A firm fundus at the level of the umbilicus with moderate lochia rubra is a
normal finding at 2 hours postpartum. The nurse should continue to monitor the patient's
uterine tone, fundal height, and lochia. Options A, C, and D are interventions for abnormal
findings such as uterine atony or excessive bleeding.
,2. A 32-year-old G3P3 delivered a term infant 1 hour ago. During the immediate postpartum
period, which nursing action is the priority to prevent postpartum hemorrhage?
A. Assess the mother's pain level
B. Assess the fundus for firmness and position
C. Initiate breastfeeding or breast stimulation
D. Administer Rh immunoglobulin if indicated
Correct Answer: B
Explanation: The priority in the immediate postpartum period is to prevent postpartum
hemorrhage by assessing the fundus for firmness and position. Uterine atony is the leading
cause of early postpartum hemorrhage. Options A, C, and D are important but secondary to
hemorrhage prevention.
3. A 25-year-old G2P2 delivered a 9 lb infant 30 minutes ago. The nurse notes that the
patient's fundus is boggy, deviated to the right, and located above the umbilicus. Which of
the following is the most appropriate initial nursing action?
,A. Administer oxytocin 10 units IM
B. Assess for a distended bladder
C. Massage the fundus
D. Notify the healthcare provider
Correct Answer: B
Explanation: A boggy fundus that is deviated to the right or left often indicates a distended
bladder, which prevents the uterus from contracting effectively. The first action is to have the
patient void or insert a straight catheter to empty the bladder. Massage may be needed after
the bladder is emptied.
4. A 30-year-old G2P2 delivered 4 hours ago. The nurse notes that the patient's lochia is
bright red with a moderate amount of small clots. Which assessment finding would indicate
that the patient's bleeding is within normal limits?
A. Saturating one perineal pad per hour
B. Saturating two perineal pads in 30 minutes
C. Saturating one perineal pad in 4 hours
D. Saturating three perineal pads in 2 hours
, Correct Answer: C
Explanation: Normal lochia flow in the immediate postpartum period is moderate, with one
pad saturated in 1-2 hours. Saturating one pad in 4 hours is within normal limits. Saturating one
pad per hour may be normal, but option C is the most clearly normal. Saturating two pads in 30
minutes or three pads in 2 hours is excessive and indicates hemorrhage.
5. A 27-year-old G1P1 delivered 12 hours ago. She is breastfeeding her infant. The patient
reports that she is experiencing "afterpains" with breastfeeding. The nurse's best response is:
A. "Afterpains are a sign of a complication and you should stop breastfeeding."
B. "Breastfeeding releases oxytocin, which causes uterine contractions and may increase
afterpains."
C. "You should take ibuprofen and avoid breastfeeding until the pain subsides."
D. "Afterpains indicate that your uterus is not contracting effectively."
Correct Answer: B
Explanation: Breastfeeding stimulates the release of oxytocin, which causes uterine
contractions. These contractions, known as "afterpains," are more common and intense in
(2026) | Advanced/Hard Difficulty | Professional Level |
100% Pass Guaranteed | Graded A+
1. A 28-year-old patient who is G2P2 gave birth to a healthy 7 lb 8 oz infant via vaginal
delivery 2 hours ago. The nurse notes that her fundus is firm, midline, and at the level of the
umbilicus. The patient has moderate lochia rubra with a few small clots. Which nursing action
is most appropriate?
A. Massage the fundus vigorously until it becomes boggy
B. Continue to monitor the patient's uterine tone and lochia
C. Notify the healthcare provider of an abnormal assessment
D. Administer oxytocin 10 units IM
Correct Answer: B
Explanation: A firm fundus at the level of the umbilicus with moderate lochia rubra is a
normal finding at 2 hours postpartum. The nurse should continue to monitor the patient's
uterine tone, fundal height, and lochia. Options A, C, and D are interventions for abnormal
findings such as uterine atony or excessive bleeding.
,2. A 32-year-old G3P3 delivered a term infant 1 hour ago. During the immediate postpartum
period, which nursing action is the priority to prevent postpartum hemorrhage?
A. Assess the mother's pain level
B. Assess the fundus for firmness and position
C. Initiate breastfeeding or breast stimulation
D. Administer Rh immunoglobulin if indicated
Correct Answer: B
Explanation: The priority in the immediate postpartum period is to prevent postpartum
hemorrhage by assessing the fundus for firmness and position. Uterine atony is the leading
cause of early postpartum hemorrhage. Options A, C, and D are important but secondary to
hemorrhage prevention.
3. A 25-year-old G2P2 delivered a 9 lb infant 30 minutes ago. The nurse notes that the
patient's fundus is boggy, deviated to the right, and located above the umbilicus. Which of
the following is the most appropriate initial nursing action?
,A. Administer oxytocin 10 units IM
B. Assess for a distended bladder
C. Massage the fundus
D. Notify the healthcare provider
Correct Answer: B
Explanation: A boggy fundus that is deviated to the right or left often indicates a distended
bladder, which prevents the uterus from contracting effectively. The first action is to have the
patient void or insert a straight catheter to empty the bladder. Massage may be needed after
the bladder is emptied.
4. A 30-year-old G2P2 delivered 4 hours ago. The nurse notes that the patient's lochia is
bright red with a moderate amount of small clots. Which assessment finding would indicate
that the patient's bleeding is within normal limits?
A. Saturating one perineal pad per hour
B. Saturating two perineal pads in 30 minutes
C. Saturating one perineal pad in 4 hours
D. Saturating three perineal pads in 2 hours
, Correct Answer: C
Explanation: Normal lochia flow in the immediate postpartum period is moderate, with one
pad saturated in 1-2 hours. Saturating one pad in 4 hours is within normal limits. Saturating one
pad per hour may be normal, but option C is the most clearly normal. Saturating two pads in 30
minutes or three pads in 2 hours is excessive and indicates hemorrhage.
5. A 27-year-old G1P1 delivered 12 hours ago. She is breastfeeding her infant. The patient
reports that she is experiencing "afterpains" with breastfeeding. The nurse's best response is:
A. "Afterpains are a sign of a complication and you should stop breastfeeding."
B. "Breastfeeding releases oxytocin, which causes uterine contractions and may increase
afterpains."
C. "You should take ibuprofen and avoid breastfeeding until the pain subsides."
D. "Afterpains indicate that your uterus is not contracting effectively."
Correct Answer: B
Explanation: Breastfeeding stimulates the release of oxytocin, which causes uterine
contractions. These contractions, known as "afterpains," are more common and intense in
