NUR 231 Exam 3 Actual Exam V3 | NUR 231 Childbearing & Child
Caring Family (NUR231 Exam 3) | Galen College of Nursing
1. A nurse is assessing a client 2 hours postpartum and finds the fundus is boggy and shifted
to the right of the midline. Which of the following actions should the nurse take first?
A. Perform a vigorous fundal massage
B. Notify the healthcare provider immediately
C. Administer a bolus of oxytocin as prescribed
D. Assist the client to the bathroom to void
Answer: D
Rationale: A fundus that is displaced to the right is a classic sign of bladder distention. A
full bladder prevents the uterus from contracting effectively, leading to uterine atony and
potential hemorrhage. Assisting the client to void will allow the uterus to return to the
midline and contract properly.
2. A newborn is being evaluated at 1 minute of life. The infant has a heart rate of 110 bpm, a
slow/irregular respiratory effort, some flexion of the extremities, a grimace in response to a
suction catheter, and a pink body with blue extremities. What is the calculated APGAR score?
A. 5
B. 8
C. 7
D. 6
Answer: D
Rationale: The heart rate >100 is 2 points, slow respiration is 1 point, some flexion is 1
point, grimace is 1 point, and acrocyanosis is 1 point. This results in a total APGAR score of
6. An APGAR score of 6 at 1 minute indicates that the infant may require some resuscitative
stabilization.
3. The nurse is teaching a postpartum client about the ‘taking-in’ phase of maternal
adaptation. Which behavior should the nurse expect the client to exhibit during this phase?
A. Active interest in learning newborn care skills
B. Assuming full responsibility for the infant’s feeding schedule
C. Preoccupation with her own needs and retelling her birth story
D. Focusing on the relationship between the infant and siblings
,Answer: C
Rationale: The taking-in phase occurs during the first 24 to 48 hours after birth. During
this time, the mother is often passive and dependent, focusing on her own needs for food
and sleep. She frequently desires to talk about her labor and birth experience to integrate it
into reality.
4. A nurse is caring for a newborn immediately following birth. Which of the following nursing
interventions is the priority to prevent heat loss via evaporation?
A. Placing the infant on a pre-warmed radiant warmer
B. Closing the doors to prevent drafts in the room
C. Drying the infant thoroughly with warm blankets
D. Keeping the infant away from cold outside walls
Answer: C
Rationale: Evaporation occurs when moisture on the skin is converted to vapor, carrying
heat away from the body. Drying the newborn immediately after birth is the most effective
way to prevent this specific type of heat loss. Other methods of heat loss include
conduction, convection, and radiation, which require different interventions.
5. A postpartum client reports painful, hard breasts on day 4 after delivery. She is
breastfeeding her infant. Which instruction should the nurse provide to manage this
engorgement?
A. Avoid breastfeeding for 24 hours to let the breasts rest
B. Apply cold cabbage leaves to the breasts between feedings
C. Use a tight-fitting bra to suppress milk production
D. Limit fluid intake to 1 liter per day
Answer: B
Rationale: Engorgement is a temporary condition that occurs as the milk supply increases.
Cold cabbage leaves contain properties that help reduce swelling and discomfort when
applied between feedings. The nurse should also encourage frequent breastfeeding to
empty the breasts and maintain supply.
6. A nurse is assessing a client for postpartum hemorrhage. Which of the following
medications is contraindicated for a client with a history of gestational hypertension?
A. Oxytocin
B. Misoprostol
C. Methylergonovine
, D. Carboprost
Answer: C
Rationale: Methylergonovine is an ergot alkaloid used to treat postpartum hemorrhage by
causing uterine contractions. However, it also causes significant vasoconstriction and can
lead to a dangerous increase in blood pressure. Therefore, it is strictly contraindicated in
patients with any form of hypertension.
7. A nurse is observing a new mother breastfeeding her 24-hour-old infant. Which of the
following observations indicates a successful latch?
A. The infant’s lips are tucked inward against the breast
B. The mother reports a sharp, pinching sensation throughout the feed
C. The infant’s nose and chin are touching the breast
D. The infant makes loud smacking sounds while sucking
Answer: C
Rationale: A proper latch involves the infant taking a large portion of the areola into the
mouth. The nose and chin should be touching or very close to the breast to ensure a deep
latch. Inward-tucked lips, smacking sounds, and sharp pain are all indicators of a poor latch
that needs correction.
8. A nurse is preparing to administer the Hepatitis B vaccine to a newborn. Which of the
following sites is the most appropriate for this injection?
A. Vastus lateralis muscle
B. Dorsogluteal muscle
C. Deltoid muscle
D. Rectus femoris muscle
Answer: A
Rationale: The vastus lateralis is the preferred site for all intramuscular injections in
newborns and infants. This muscle is the most developed at birth and lacks major nerves or
blood vessels that could be damaged. The dorsogluteal site is avoided due to the proximity
of the sciatic nerve.
9. Which finding in a 12-hour-old newborn should the nurse report to the provider
immediately?
A. Acrocyanosis of the hands and feet
B. Jaundice of the face and sclera
C. Erythema toxicum on the trunk
Caring Family (NUR231 Exam 3) | Galen College of Nursing
1. A nurse is assessing a client 2 hours postpartum and finds the fundus is boggy and shifted
to the right of the midline. Which of the following actions should the nurse take first?
A. Perform a vigorous fundal massage
B. Notify the healthcare provider immediately
C. Administer a bolus of oxytocin as prescribed
D. Assist the client to the bathroom to void
Answer: D
Rationale: A fundus that is displaced to the right is a classic sign of bladder distention. A
full bladder prevents the uterus from contracting effectively, leading to uterine atony and
potential hemorrhage. Assisting the client to void will allow the uterus to return to the
midline and contract properly.
2. A newborn is being evaluated at 1 minute of life. The infant has a heart rate of 110 bpm, a
slow/irregular respiratory effort, some flexion of the extremities, a grimace in response to a
suction catheter, and a pink body with blue extremities. What is the calculated APGAR score?
A. 5
B. 8
C. 7
D. 6
Answer: D
Rationale: The heart rate >100 is 2 points, slow respiration is 1 point, some flexion is 1
point, grimace is 1 point, and acrocyanosis is 1 point. This results in a total APGAR score of
6. An APGAR score of 6 at 1 minute indicates that the infant may require some resuscitative
stabilization.
3. The nurse is teaching a postpartum client about the ‘taking-in’ phase of maternal
adaptation. Which behavior should the nurse expect the client to exhibit during this phase?
A. Active interest in learning newborn care skills
B. Assuming full responsibility for the infant’s feeding schedule
C. Preoccupation with her own needs and retelling her birth story
D. Focusing on the relationship between the infant and siblings
,Answer: C
Rationale: The taking-in phase occurs during the first 24 to 48 hours after birth. During
this time, the mother is often passive and dependent, focusing on her own needs for food
and sleep. She frequently desires to talk about her labor and birth experience to integrate it
into reality.
4. A nurse is caring for a newborn immediately following birth. Which of the following nursing
interventions is the priority to prevent heat loss via evaporation?
A. Placing the infant on a pre-warmed radiant warmer
B. Closing the doors to prevent drafts in the room
C. Drying the infant thoroughly with warm blankets
D. Keeping the infant away from cold outside walls
Answer: C
Rationale: Evaporation occurs when moisture on the skin is converted to vapor, carrying
heat away from the body. Drying the newborn immediately after birth is the most effective
way to prevent this specific type of heat loss. Other methods of heat loss include
conduction, convection, and radiation, which require different interventions.
5. A postpartum client reports painful, hard breasts on day 4 after delivery. She is
breastfeeding her infant. Which instruction should the nurse provide to manage this
engorgement?
A. Avoid breastfeeding for 24 hours to let the breasts rest
B. Apply cold cabbage leaves to the breasts between feedings
C. Use a tight-fitting bra to suppress milk production
D. Limit fluid intake to 1 liter per day
Answer: B
Rationale: Engorgement is a temporary condition that occurs as the milk supply increases.
Cold cabbage leaves contain properties that help reduce swelling and discomfort when
applied between feedings. The nurse should also encourage frequent breastfeeding to
empty the breasts and maintain supply.
6. A nurse is assessing a client for postpartum hemorrhage. Which of the following
medications is contraindicated for a client with a history of gestational hypertension?
A. Oxytocin
B. Misoprostol
C. Methylergonovine
, D. Carboprost
Answer: C
Rationale: Methylergonovine is an ergot alkaloid used to treat postpartum hemorrhage by
causing uterine contractions. However, it also causes significant vasoconstriction and can
lead to a dangerous increase in blood pressure. Therefore, it is strictly contraindicated in
patients with any form of hypertension.
7. A nurse is observing a new mother breastfeeding her 24-hour-old infant. Which of the
following observations indicates a successful latch?
A. The infant’s lips are tucked inward against the breast
B. The mother reports a sharp, pinching sensation throughout the feed
C. The infant’s nose and chin are touching the breast
D. The infant makes loud smacking sounds while sucking
Answer: C
Rationale: A proper latch involves the infant taking a large portion of the areola into the
mouth. The nose and chin should be touching or very close to the breast to ensure a deep
latch. Inward-tucked lips, smacking sounds, and sharp pain are all indicators of a poor latch
that needs correction.
8. A nurse is preparing to administer the Hepatitis B vaccine to a newborn. Which of the
following sites is the most appropriate for this injection?
A. Vastus lateralis muscle
B. Dorsogluteal muscle
C. Deltoid muscle
D. Rectus femoris muscle
Answer: A
Rationale: The vastus lateralis is the preferred site for all intramuscular injections in
newborns and infants. This muscle is the most developed at birth and lacks major nerves or
blood vessels that could be damaged. The dorsogluteal site is avoided due to the proximity
of the sciatic nerve.
9. Which finding in a 12-hour-old newborn should the nurse report to the provider
immediately?
A. Acrocyanosis of the hands and feet
B. Jaundice of the face and sclera
C. Erythema toxicum on the trunk
