,NUR 231 Exam 3 | Childbearing & Child Caring Families (2026)
Q&A | Galen College
1. A nurse is assessing a newborn immediately after birth. Which finding is
considered a normal transitional finding?
A) Heart rate of 90 beats per minute
B) Respiratory rate of 50 breaths per minute
C) Central cyanosis
D) Grunting with nasal flaring
Correct Answer: Respiratory rate of 50 breaths per minute
Rationale: A normal newborn respiratory rate is 30 to 60 breaths per minute, so a
rate of 50 is within normal limits. A heart rate of 90 is below the normal range of
120 to 160 beats per minute. Central cyanosis and grunting with nasal flaring
indicate respiratory d istress requiring immediate evaluation.
2. Which action should the nurse prioritize to prevent heat loss through evaporation
in a newborn immediately after birth?
A) Place the newborn under a radiant warmer.
B) Dry the newborn thoroughly with warm towels.
C) Apply a warm blanket over the newborn.
D) Put a hat on the newborn's head.
Correct Answer: Dry the newborn thoroughly with warm towels.
Rationale: Evaporation occurs when moisture on the skin converts to vapor, and
drying the newborn immediately after birth removes the moisture that would
otherwise cause heat loss. Placing the newborn under a radiant warmer, applying
blankets, and covering the head address other mechanisms of heat loss: radiation,
conduction, and convection.
3. A newborn's 1 - minute APGAR score is 3. Which intervention is the priority?
,A) Provide routine newborn care
B) Administer oxygen and stimulate
C) Begin positive pressure ventilation
D) Perform chest compressions
Correct Answer: Begin positive pressure ventilation
Rationale: An APGAR score of 0 to 3 indicates severe distress requiring immediate
resuscitation. Positive pressure ventilation is the priority for a newborn who is not
breathing effectively. Chest compressions are indicated if the heart rate remains
below 60 after e ffective ventilation.
4. A nurse is assessing a newborn and notes a bluish - black pigmented area on the
sacrum. How should the nurse document this finding?
A) Child abuse bruises
B) Erythema toxicum
C) Congenital dermal melanocytosis
D) Telangiectatic nevi
Correct Answer: Congenital dermal melanocytosis
Rationale: Congenital dermal melanocytosis, also known as Mongolian spots, are
flat, bluish - gray patches commonly found on the lower back or buttocks of
newborns with darker skin. They are benign and should not be mistaken for bruises.
Erythema toxicum is a rash, an d telangiectatic nevi are pinkish capillary
hemangiomas.
5. Which finding in a newborn requires immediate notification of the provider?
A) Respiratory rate of 50 breaths per minute
B) Heart rate of 130 beats per minute
C) Grunting and nasal flaring
D) Acrocyanosis of the hands and feet
Correct Answer: Grunting and nasal flaring
, Rationale: Grunting and nasal flaring are signs of respiratory distress requiring
immediate evaluation. A respiratory rate of 50 and heart rate of 130 are within
normal limits. Acrocyanosis is a common, benign finding in newborns.
6. A postpartum client has a boggy fundus that is displaced to the right. What should
the nurse do first?
A) Administer methylergonovine
B) Assist the client to void
C) Notify the healthcare provider
D) Perform fundal massage
Correct Answer: Assist the client to void
Rationale: A full bladder lifts the uterus and prevents contraction. Emptying the
bladder often allows the uterus to return to midline and become firm. Fundal
massage, administration of uterotonics, and notification of the provider may be
necessary but addressing bl adder distention is the first priority.
7. A nurse is assessing a client who is 24 hours postpartum. Which finding should
the nurse report to the provider immediately?
A) Fundus firm at the umbilicus
B) Lochia rubra with small clots
C) Saturation of one perineal pad in 15 minutes
D) Mild afterpains during breastfeeding
Correct Answer: Saturation of one perineal pad in 15 minutes
Rationale: Saturating a perineal pad in 15 minutes indicates excessive bleeding and
possible postpartum hemorrhage, requiring immediate intervention. A firm fundus
at the umbilicus, lochia rubra with small clots, and mild afterpains are expected
findings in the imme diate postpartum period.
Q&A | Galen College
1. A nurse is assessing a newborn immediately after birth. Which finding is
considered a normal transitional finding?
A) Heart rate of 90 beats per minute
B) Respiratory rate of 50 breaths per minute
C) Central cyanosis
D) Grunting with nasal flaring
Correct Answer: Respiratory rate of 50 breaths per minute
Rationale: A normal newborn respiratory rate is 30 to 60 breaths per minute, so a
rate of 50 is within normal limits. A heart rate of 90 is below the normal range of
120 to 160 beats per minute. Central cyanosis and grunting with nasal flaring
indicate respiratory d istress requiring immediate evaluation.
2. Which action should the nurse prioritize to prevent heat loss through evaporation
in a newborn immediately after birth?
A) Place the newborn under a radiant warmer.
B) Dry the newborn thoroughly with warm towels.
C) Apply a warm blanket over the newborn.
D) Put a hat on the newborn's head.
Correct Answer: Dry the newborn thoroughly with warm towels.
Rationale: Evaporation occurs when moisture on the skin converts to vapor, and
drying the newborn immediately after birth removes the moisture that would
otherwise cause heat loss. Placing the newborn under a radiant warmer, applying
blankets, and covering the head address other mechanisms of heat loss: radiation,
conduction, and convection.
3. A newborn's 1 - minute APGAR score is 3. Which intervention is the priority?
,A) Provide routine newborn care
B) Administer oxygen and stimulate
C) Begin positive pressure ventilation
D) Perform chest compressions
Correct Answer: Begin positive pressure ventilation
Rationale: An APGAR score of 0 to 3 indicates severe distress requiring immediate
resuscitation. Positive pressure ventilation is the priority for a newborn who is not
breathing effectively. Chest compressions are indicated if the heart rate remains
below 60 after e ffective ventilation.
4. A nurse is assessing a newborn and notes a bluish - black pigmented area on the
sacrum. How should the nurse document this finding?
A) Child abuse bruises
B) Erythema toxicum
C) Congenital dermal melanocytosis
D) Telangiectatic nevi
Correct Answer: Congenital dermal melanocytosis
Rationale: Congenital dermal melanocytosis, also known as Mongolian spots, are
flat, bluish - gray patches commonly found on the lower back or buttocks of
newborns with darker skin. They are benign and should not be mistaken for bruises.
Erythema toxicum is a rash, an d telangiectatic nevi are pinkish capillary
hemangiomas.
5. Which finding in a newborn requires immediate notification of the provider?
A) Respiratory rate of 50 breaths per minute
B) Heart rate of 130 beats per minute
C) Grunting and nasal flaring
D) Acrocyanosis of the hands and feet
Correct Answer: Grunting and nasal flaring
, Rationale: Grunting and nasal flaring are signs of respiratory distress requiring
immediate evaluation. A respiratory rate of 50 and heart rate of 130 are within
normal limits. Acrocyanosis is a common, benign finding in newborns.
6. A postpartum client has a boggy fundus that is displaced to the right. What should
the nurse do first?
A) Administer methylergonovine
B) Assist the client to void
C) Notify the healthcare provider
D) Perform fundal massage
Correct Answer: Assist the client to void
Rationale: A full bladder lifts the uterus and prevents contraction. Emptying the
bladder often allows the uterus to return to midline and become firm. Fundal
massage, administration of uterotonics, and notification of the provider may be
necessary but addressing bl adder distention is the first priority.
7. A nurse is assessing a client who is 24 hours postpartum. Which finding should
the nurse report to the provider immediately?
A) Fundus firm at the umbilicus
B) Lochia rubra with small clots
C) Saturation of one perineal pad in 15 minutes
D) Mild afterpains during breastfeeding
Correct Answer: Saturation of one perineal pad in 15 minutes
Rationale: Saturating a perineal pad in 15 minutes indicates excessive bleeding and
possible postpartum hemorrhage, requiring immediate intervention. A firm fundus
at the umbilicus, lochia rubra with small clots, and mild afterpains are expected
findings in the imme diate postpartum period.
