NUR 254 Exam 2 | Galen College | Postpartum Management
and Neonatal Care Exam With Detailed Rationales
Course Code: NUR 254
Course Name: Postpartum Management and Neonatal Care
Academic Year: 2026/2027
51.What is the priority nursing intervention?
A. Administer a continuous intravenous infusion of Oxytocin at the
maximum rate.
, B. Instruct the client to empty her bladder immediately or perform a
straight catheterization, then perform a firm fundal massage .
C. Prepare the patient for an emergency exploratory laparotomy.
D. Draw a blood sample for immediate cross-matching and clotting factors.
CORRECT ANSWER: B
RATIONALE: A postpartum uterus that is boggy, elevated above the
umbilicus, and shifted to the right is a classic sign of uterine displacement due
to a distended bladder . A full bladder prevents the uterus from contracting
efficiently, leading to uterine atony and severe postpartum hemorrhage (PPH). The
priority action is to empty the bladder (via voiding or catheterization) and
perform fundal massage to restore uterine tone. Distractor A is an important
collaborative step but will not resolve the mechanical displacement caused by the
bladder. Distractors C and D are advanced interventions indicated only if primary
conservative measures fail.
52.A nurse is assessing a 30-year-old postpartum client who is 6 hours post-
delivery . The client is receiving a continuous intravenous infusion of
Magnesium Sulfate for preeclampsia management. Which clinical finding
should prompt the nurse to stop the infusion immediately and anticipate
the administration of calcium gluconate?
A. A resting blood pressure reading of 142/92 mmHg.
B. An absolute absence of deep tendon reflexes (DTRs) combined with a
respiratory rate of 9 breaths/minute .
C. A total urine output of 120 mL over the last 4 hours of monitoring.
D. A complaints of mild facial flushing and warmth.
CORRECT ANSWER: B
RATIONALE: An absence of deep tendon reflexes (DTRs) and severe
respiratory depression (<12 breaths/minute) are classic signs of magnesium
sulfate toxicity . Magnesium depresses the central nervous system and
neuromuscular transmission; if toxic levels build up, it can progress to respiratory
paralysis and cardiac arrest. Distractor A is an expected high baseline for a
preeclamptic patient. Distractor C describes borderline urine output that requires
monitoring but is not an immediate sign of toxic arrest. Distractor D is a common,
benign side effect of magnesium infusion.
, 53.A 2-day-old term male newborn is being assessed in the mother's room.
The nurse notes that the infant's skin, sclera, and mucous membranes exhibit
a distinct yellow discoloration . Laboratory results demonstrate a serum
total bilirubin level of 13 mg/dL . If this hyperbilirubinemia is left
untreated and crosses the blood-brain barrier, which permanent neurological
complication is the infant at risk for?
A. Hydrocephalus secondary to aqueductal stenosis.
B. Kernicterus (Birubin Encephalopathy), causing severe athetoid
cerebral palsy, hearing loss, and cognitive deficits .
C. Acute hypoxic-ischemic encephalopathy.
D. Isolated motor unit muscular dystrophy.
CORRECT ANSWER: B
RATIONALE: High levels of unconjugated bilirubin can cross the blood-
brain barrier and deposit in the basal ganglia and brainstem nuclei, a pathological
process known as kernicterus . This causes permanent, irreversible brain damage
characterized by athetoid cerebral palsy, sensorineural hearing loss, dental
enamel dysplasia, and cognitive impairment . Distractor A is a structural CSF
anomaly. Distractor C is caused by perinatal asphyxia, not bilirubin toxicity.
Distractor D is a genetic muscular disorder.
54.A nurse is conducting a newborn physical examination on a 12-hour-old
female infant . The nurse notes a swelling on the right side of the
newborn's scalp that does not cross the cranial suture lines . How should
the nurse accurately document and explain this finding to the parents?
A. Caput succedaneum, which is a benign fluid collection that will resolve
within 24 hours.
B. Cephalohematoma, a collection of blood between the periosteum and
skull bone that does not cross suture lines and increases the risk for
jaundice .
C. Subgaleal hemorrhage, representing an acute life-threatening emergency.
D. Anencephaly secondary to incomplete neural tube fusion.
CORRECT ANSWER: B
RATIONALE: A cephalohematoma is a collection of blood between a skull
bone and its periosteum, caused by ruptured blood vessels during labor. Because it
is bounded by the periosteum, the swelling is strictly limited and does not cross
cranial suture lines . As the trapped red blood cells break down and undergo
and Neonatal Care Exam With Detailed Rationales
Course Code: NUR 254
Course Name: Postpartum Management and Neonatal Care
Academic Year: 2026/2027
51.What is the priority nursing intervention?
A. Administer a continuous intravenous infusion of Oxytocin at the
maximum rate.
, B. Instruct the client to empty her bladder immediately or perform a
straight catheterization, then perform a firm fundal massage .
C. Prepare the patient for an emergency exploratory laparotomy.
D. Draw a blood sample for immediate cross-matching and clotting factors.
CORRECT ANSWER: B
RATIONALE: A postpartum uterus that is boggy, elevated above the
umbilicus, and shifted to the right is a classic sign of uterine displacement due
to a distended bladder . A full bladder prevents the uterus from contracting
efficiently, leading to uterine atony and severe postpartum hemorrhage (PPH). The
priority action is to empty the bladder (via voiding or catheterization) and
perform fundal massage to restore uterine tone. Distractor A is an important
collaborative step but will not resolve the mechanical displacement caused by the
bladder. Distractors C and D are advanced interventions indicated only if primary
conservative measures fail.
52.A nurse is assessing a 30-year-old postpartum client who is 6 hours post-
delivery . The client is receiving a continuous intravenous infusion of
Magnesium Sulfate for preeclampsia management. Which clinical finding
should prompt the nurse to stop the infusion immediately and anticipate
the administration of calcium gluconate?
A. A resting blood pressure reading of 142/92 mmHg.
B. An absolute absence of deep tendon reflexes (DTRs) combined with a
respiratory rate of 9 breaths/minute .
C. A total urine output of 120 mL over the last 4 hours of monitoring.
D. A complaints of mild facial flushing and warmth.
CORRECT ANSWER: B
RATIONALE: An absence of deep tendon reflexes (DTRs) and severe
respiratory depression (<12 breaths/minute) are classic signs of magnesium
sulfate toxicity . Magnesium depresses the central nervous system and
neuromuscular transmission; if toxic levels build up, it can progress to respiratory
paralysis and cardiac arrest. Distractor A is an expected high baseline for a
preeclamptic patient. Distractor C describes borderline urine output that requires
monitoring but is not an immediate sign of toxic arrest. Distractor D is a common,
benign side effect of magnesium infusion.
, 53.A 2-day-old term male newborn is being assessed in the mother's room.
The nurse notes that the infant's skin, sclera, and mucous membranes exhibit
a distinct yellow discoloration . Laboratory results demonstrate a serum
total bilirubin level of 13 mg/dL . If this hyperbilirubinemia is left
untreated and crosses the blood-brain barrier, which permanent neurological
complication is the infant at risk for?
A. Hydrocephalus secondary to aqueductal stenosis.
B. Kernicterus (Birubin Encephalopathy), causing severe athetoid
cerebral palsy, hearing loss, and cognitive deficits .
C. Acute hypoxic-ischemic encephalopathy.
D. Isolated motor unit muscular dystrophy.
CORRECT ANSWER: B
RATIONALE: High levels of unconjugated bilirubin can cross the blood-
brain barrier and deposit in the basal ganglia and brainstem nuclei, a pathological
process known as kernicterus . This causes permanent, irreversible brain damage
characterized by athetoid cerebral palsy, sensorineural hearing loss, dental
enamel dysplasia, and cognitive impairment . Distractor A is a structural CSF
anomaly. Distractor C is caused by perinatal asphyxia, not bilirubin toxicity.
Distractor D is a genetic muscular disorder.
54.A nurse is conducting a newborn physical examination on a 12-hour-old
female infant . The nurse notes a swelling on the right side of the
newborn's scalp that does not cross the cranial suture lines . How should
the nurse accurately document and explain this finding to the parents?
A. Caput succedaneum, which is a benign fluid collection that will resolve
within 24 hours.
B. Cephalohematoma, a collection of blood between the periosteum and
skull bone that does not cross suture lines and increases the risk for
jaundice .
C. Subgaleal hemorrhage, representing an acute life-threatening emergency.
D. Anencephaly secondary to incomplete neural tube fusion.
CORRECT ANSWER: B
RATIONALE: A cephalohematoma is a collection of blood between a skull
bone and its periosteum, caused by ruptured blood vessels during labor. Because it
is bounded by the periosteum, the swelling is strictly limited and does not cross
cranial suture lines . As the trapped red blood cells break down and undergo
