NUR 231 Exam 4 – Maternal Nursing Comprehensive Review … 2026 Update • Verified Answers
✓ VERIFIED • 2026 UPDATE • 100% ACCURATE
NUR 231 Exam 4 – Maternal Nursing Comprehensive
Review 2026 UPDATE
Actual Exam Questions & Verified Answers
with Detailed Rationales
Document Type: Exam (Elaborations)
Academic Year:
Total Questions: 50 Multiple Choice
Includes: Correct Answers + Full Rationales
Status: Verified & Updated for 2026
Exam (Elaborations) • Actual Questions & Rationales Page 1
,NUR 231 Exam 4 – Maternal Nursing Comprehensive Review … 2026 Update • Verified Answers
Questions & Verified Answers
1. A nurse is assessing a client who is 2 hours postpartum and observes that the fundus is
displaced to the right and above the umbilicus. What is the priority nursing action?
A. Massage the fundus immediately.
B. Administer oxytocin as ordered.
C. Assist the client to the bathroom to void.
D. Notify the provider of a potential hemorrhage.
Answer: C
Rationale: A fundus that is displaced to the right and above the umbilicus is a classic sign of a full bladder,
which can prevent the uterus from contracting effectively and lead to hemorrhage. Recognizing this principle
allows the nurse to prioritize care, anticipate complications, and provide accurate patient education.
2. Which of the following describes lochia serosa?
A. Pinkish-brown discharge lasting from day 4 to day 10 postpartum.
B. Bright red discharge lasting 1-3 days postpartum.
C. Yellow-white discharge lasting from day 11 to 6 weeks postpartum.
D. Bloody discharge containing small clots and decidua.
Answer: A
Rationale: Lochia serosa is the second stage of postpartum discharge, appearing pinkish- brown and typically
lasting from the 4th to the 10th day after delivery. Exam questions often test the ability to distinguish this
concept from closely related distractors, making a clear rationale essential for mastery. Applying this knowledge
in clinical settings supports safe, evidence-based practice and improves patient outcomes.
3. A newborn is being assessed at 1 minute of life. The heart rate is 110, there is a weak cry,
some flexion of extremities, the body is pink with blue hands and feet, and the infant grimaces
when suctioned. What is the APGAR score?
A. 6
B. 8
C. 7
D. 9
Answer: C
Rationale: Heart rate > 100 (2), Weak cry (1), Some flexion (1), Acrocyanosis (1), Grimace (2) = 7. This is an
important clinical concept because selecting the correct answer (C) requires understanding both the
pathophysiology and the practical nursing implications. Recognizing this principle allows the nurse to prioritize
care, anticipate complications, and provide accurate patient education.
Exam (Elaborations) • Actual Questions & Rationales Page 2
, NUR 231 Exam 4 – Maternal Nursing Comprehensive Review … 2026 Update • Verified Answers
4. Which medication is standardly administered to newborns within 1 hour of birth to prevent
ophthalmia neonatorum?
A. Vitamin K (Phytonadione)
B. Hepatitis B vaccine
C. Triple dye
D. Erythromycin ophthalmic ointment
Answer: D
Rationale: Erythromycin ointment is applied to the newborn’s eyes to prevent blindness caused by Neisseria
gonorrhoeae or Chlamydia trachomatis acquired during birth. Applying this knowledge in clinical settings
supports safe, evidence-based practice and improves patient outcomes. This is an important clinical concept
because selecting the correct answer (D) requires understanding both the pathophysiology and the practical
nursing implications.
5. A nurse is teaching a postpartum client about mastitis. Which statement by the client
indicates a need for further teaching?
A. I should continue to breastfeed on both sides.
B. I will wear a supportive, non-underwire bra.
C. I need to take all my antibiotics as prescribed.
D. I will stop breastfeeding on the affected side until the infection clears.
Answer: D
Rationale: Emptying the breast is crucial in managing mastitis. Stopping breastfeeding on the affected side can
lead to an abscess or worsen the infection. Recognizing this principle allows the nurse to prioritize care,
anticipate complications, and provide accurate patient education. Exam questions often test the ability to
distinguish this concept from closely related distractors, making a clear rationale essential for mastery.
6. Which of the following is the most common cause of early postpartum hemorrhage (within
the first 24 hours)?
A. Retained placental fragments
B. Uterine atony
C. Lacerations of the birth canal
D. Disseminated intravascular coagulation (DIC)
Answer: B
Rationale: Uterine atony, the failure of the uterus to contract after birth, is the leading cause of early
postpartum hemorrhage. Applying this knowledge in clinical settings supports safe, evidence-based practice
and improves patient outcomes. This is an important clinical concept because selecting the correct answer (B)
requires understanding both the pathophysiology and the practical nursing implications.
Exam (Elaborations) • Actual Questions & Rationales Page 3
✓ VERIFIED • 2026 UPDATE • 100% ACCURATE
NUR 231 Exam 4 – Maternal Nursing Comprehensive
Review 2026 UPDATE
Actual Exam Questions & Verified Answers
with Detailed Rationales
Document Type: Exam (Elaborations)
Academic Year:
Total Questions: 50 Multiple Choice
Includes: Correct Answers + Full Rationales
Status: Verified & Updated for 2026
Exam (Elaborations) • Actual Questions & Rationales Page 1
,NUR 231 Exam 4 – Maternal Nursing Comprehensive Review … 2026 Update • Verified Answers
Questions & Verified Answers
1. A nurse is assessing a client who is 2 hours postpartum and observes that the fundus is
displaced to the right and above the umbilicus. What is the priority nursing action?
A. Massage the fundus immediately.
B. Administer oxytocin as ordered.
C. Assist the client to the bathroom to void.
D. Notify the provider of a potential hemorrhage.
Answer: C
Rationale: A fundus that is displaced to the right and above the umbilicus is a classic sign of a full bladder,
which can prevent the uterus from contracting effectively and lead to hemorrhage. Recognizing this principle
allows the nurse to prioritize care, anticipate complications, and provide accurate patient education.
2. Which of the following describes lochia serosa?
A. Pinkish-brown discharge lasting from day 4 to day 10 postpartum.
B. Bright red discharge lasting 1-3 days postpartum.
C. Yellow-white discharge lasting from day 11 to 6 weeks postpartum.
D. Bloody discharge containing small clots and decidua.
Answer: A
Rationale: Lochia serosa is the second stage of postpartum discharge, appearing pinkish- brown and typically
lasting from the 4th to the 10th day after delivery. Exam questions often test the ability to distinguish this
concept from closely related distractors, making a clear rationale essential for mastery. Applying this knowledge
in clinical settings supports safe, evidence-based practice and improves patient outcomes.
3. A newborn is being assessed at 1 minute of life. The heart rate is 110, there is a weak cry,
some flexion of extremities, the body is pink with blue hands and feet, and the infant grimaces
when suctioned. What is the APGAR score?
A. 6
B. 8
C. 7
D. 9
Answer: C
Rationale: Heart rate > 100 (2), Weak cry (1), Some flexion (1), Acrocyanosis (1), Grimace (2) = 7. This is an
important clinical concept because selecting the correct answer (C) requires understanding both the
pathophysiology and the practical nursing implications. Recognizing this principle allows the nurse to prioritize
care, anticipate complications, and provide accurate patient education.
Exam (Elaborations) • Actual Questions & Rationales Page 2
, NUR 231 Exam 4 – Maternal Nursing Comprehensive Review … 2026 Update • Verified Answers
4. Which medication is standardly administered to newborns within 1 hour of birth to prevent
ophthalmia neonatorum?
A. Vitamin K (Phytonadione)
B. Hepatitis B vaccine
C. Triple dye
D. Erythromycin ophthalmic ointment
Answer: D
Rationale: Erythromycin ointment is applied to the newborn’s eyes to prevent blindness caused by Neisseria
gonorrhoeae or Chlamydia trachomatis acquired during birth. Applying this knowledge in clinical settings
supports safe, evidence-based practice and improves patient outcomes. This is an important clinical concept
because selecting the correct answer (D) requires understanding both the pathophysiology and the practical
nursing implications.
5. A nurse is teaching a postpartum client about mastitis. Which statement by the client
indicates a need for further teaching?
A. I should continue to breastfeed on both sides.
B. I will wear a supportive, non-underwire bra.
C. I need to take all my antibiotics as prescribed.
D. I will stop breastfeeding on the affected side until the infection clears.
Answer: D
Rationale: Emptying the breast is crucial in managing mastitis. Stopping breastfeeding on the affected side can
lead to an abscess or worsen the infection. Recognizing this principle allows the nurse to prioritize care,
anticipate complications, and provide accurate patient education. Exam questions often test the ability to
distinguish this concept from closely related distractors, making a clear rationale essential for mastery.
6. Which of the following is the most common cause of early postpartum hemorrhage (within
the first 24 hours)?
A. Retained placental fragments
B. Uterine atony
C. Lacerations of the birth canal
D. Disseminated intravascular coagulation (DIC)
Answer: B
Rationale: Uterine atony, the failure of the uterus to contract after birth, is the leading cause of early
postpartum hemorrhage. Applying this knowledge in clinical settings supports safe, evidence-based practice
and improves patient outcomes. This is an important clinical concept because selecting the correct answer (B)
requires understanding both the pathophysiology and the practical nursing implications.
Exam (Elaborations) • Actual Questions & Rationales Page 3
