,South College NSG 3332 Exam 3 | Maternal-Infant Nursing
Care (2026) Q&A
1. A postpartum client is experiencing a boggy uterus with heavy bleeding. The nurse
massages the fundus, but it remains boggy. What is the nurse's priority action?
A) Administer oxytocin as prescribed
B) Continue to massage the fundus
C) Insert a Foley catheter
D) Assess the client's blood pressure
Correct Answer: Administer oxytocin as prescribed
Rationale: A boggy uterus that does not respond to massage indicates uterine
atony, the most common cause of postpartum hemorrhage. Administering oxytocin
is the next step to promote uterine contraction and control bleeding. While assessing
blood pressure is important, administering the medication directly addresses the
cause of the hemorrhage.
2. A patient who is 2 hours postpartum has saturated two perineal pads in 15
minutes. The nurse assesses a firm fundus at the umbilicus. What is the most likely
cause of this bleeding?
A) Uterine atony
B) Retained placental fragments
C) A vaginal or cervical laceration
D) Uterine inversion
Correct Answer: A vaginal or cervical laceration
,Rationale: When the fundus is firm but the client is experiencing heavy bleeding, the
source is likely a laceration of the cervix, vagina, or perineum. Uterine atony would
present with a boggy fundus. Retained fragments typically cause intermittent
bleeding with a boggy uterus.
3. The nurse is assessing a newborn who is 12 hours old. The infant's axillary
temperature is 36.2°C (97.2°F). What is the nurse's priority action?
A) Document the finding as normal
B) Apply a warm blanket and place under a radiant warmer
C) Notify the healthcare provider
D) Administer a prescribed antipyretic
Correct Answer: Apply a warm blanket and place under a radiant warmer
Rationale: A temperature below 36.5°C (97.7°F) indicates hypothermia in a newborn.
The priority is to warm the infant using a radiant warmer and warm blankets.
Hypothermia can lead to hypoglycemia, respiratory distress, and increased oxygen
consumption.
4. A breastfeeding mother asks the nurse why her newborn's first stool is black and
tarry. What is the best response by the nurse?
A) "This can be caused by blood in the stool, and I will check it to make sure
everything is okay."
B) "Let me call the physician and see if we need to supplement the baby with
formula."
C) "The stool is normal and called meconium. The baby may pass this for the first day
or two."
D) "The iron you took during the pregnancy caused the stool to be tarry and thick."
, Correct Answer: "The stool is normal and called meconium. The baby may pass this
for the first day or two."
Rationale: Meconium is the first stool of a newborn, composed of amniotic fluid,
mucus, and bile. It is typically dark greenish-black, tarry, and sticky. The passage of
meconium is a normal physiological process and indicates bowel function.
5. The nurse is teaching a client how to bottle-feed her premature infant. Which
instruction should the nurse include?
A) Pace the feeding to allow for breathing breaks.
B) Hold the baby in a supine position to prevent fatigue.
C) Use a high-flow nipple to make suckling easier.
D) A decrease in heart rate is expected and feeding can continue.
Correct Answer: Pace the feeding to allow for breathing breaks.
Rationale: Premature infants may not have a coordinated suck-swallow-breathe
pattern. Pacing the feeding gives the infant time to breathe, reducing the risk of
apnea, bradycardia, and aspiration. The infant should be held in a semi-upright
position, and slow-flow nipples should be used.
6. A breastfeeding client asks the nurse, "Why has my baby lost 5 ounces since she
was born?" What is the best response by the nurse?
A) "She may lose weight until your milk comes in."
B) "It is normal for the baby to lose 5 to 10% of her weight during the first week due
to diuresis."
C) "The baby may be dehydrated, which is not uncommon in a breastfed baby."
D) "The baby is having bowel movements, which results in a weight change."
Care (2026) Q&A
1. A postpartum client is experiencing a boggy uterus with heavy bleeding. The nurse
massages the fundus, but it remains boggy. What is the nurse's priority action?
A) Administer oxytocin as prescribed
B) Continue to massage the fundus
C) Insert a Foley catheter
D) Assess the client's blood pressure
Correct Answer: Administer oxytocin as prescribed
Rationale: A boggy uterus that does not respond to massage indicates uterine
atony, the most common cause of postpartum hemorrhage. Administering oxytocin
is the next step to promote uterine contraction and control bleeding. While assessing
blood pressure is important, administering the medication directly addresses the
cause of the hemorrhage.
2. A patient who is 2 hours postpartum has saturated two perineal pads in 15
minutes. The nurse assesses a firm fundus at the umbilicus. What is the most likely
cause of this bleeding?
A) Uterine atony
B) Retained placental fragments
C) A vaginal or cervical laceration
D) Uterine inversion
Correct Answer: A vaginal or cervical laceration
,Rationale: When the fundus is firm but the client is experiencing heavy bleeding, the
source is likely a laceration of the cervix, vagina, or perineum. Uterine atony would
present with a boggy fundus. Retained fragments typically cause intermittent
bleeding with a boggy uterus.
3. The nurse is assessing a newborn who is 12 hours old. The infant's axillary
temperature is 36.2°C (97.2°F). What is the nurse's priority action?
A) Document the finding as normal
B) Apply a warm blanket and place under a radiant warmer
C) Notify the healthcare provider
D) Administer a prescribed antipyretic
Correct Answer: Apply a warm blanket and place under a radiant warmer
Rationale: A temperature below 36.5°C (97.7°F) indicates hypothermia in a newborn.
The priority is to warm the infant using a radiant warmer and warm blankets.
Hypothermia can lead to hypoglycemia, respiratory distress, and increased oxygen
consumption.
4. A breastfeeding mother asks the nurse why her newborn's first stool is black and
tarry. What is the best response by the nurse?
A) "This can be caused by blood in the stool, and I will check it to make sure
everything is okay."
B) "Let me call the physician and see if we need to supplement the baby with
formula."
C) "The stool is normal and called meconium. The baby may pass this for the first day
or two."
D) "The iron you took during the pregnancy caused the stool to be tarry and thick."
, Correct Answer: "The stool is normal and called meconium. The baby may pass this
for the first day or two."
Rationale: Meconium is the first stool of a newborn, composed of amniotic fluid,
mucus, and bile. It is typically dark greenish-black, tarry, and sticky. The passage of
meconium is a normal physiological process and indicates bowel function.
5. The nurse is teaching a client how to bottle-feed her premature infant. Which
instruction should the nurse include?
A) Pace the feeding to allow for breathing breaks.
B) Hold the baby in a supine position to prevent fatigue.
C) Use a high-flow nipple to make suckling easier.
D) A decrease in heart rate is expected and feeding can continue.
Correct Answer: Pace the feeding to allow for breathing breaks.
Rationale: Premature infants may not have a coordinated suck-swallow-breathe
pattern. Pacing the feeding gives the infant time to breathe, reducing the risk of
apnea, bradycardia, and aspiration. The infant should be held in a semi-upright
position, and slow-flow nipples should be used.
6. A breastfeeding client asks the nurse, "Why has my baby lost 5 ounces since she
was born?" What is the best response by the nurse?
A) "She may lose weight until your milk comes in."
B) "It is normal for the baby to lose 5 to 10% of her weight during the first week due
to diuresis."
C) "The baby may be dehydrated, which is not uncommon in a breastfed baby."
D) "The baby is having bowel movements, which results in a weight change."
