NUR 230 MATERNAL EXAM 2
QUESTIONS AND CORRECT ANSWERS
(VERIFIED ANSWERS) PLUS RATIONALES
2026 Q&A | INSTANT DOWNLOAD PDF
Core Domains
Postpartum Assessment and Nursing Care
Newborn Assessment and Transition
Lactation and Infant Feeding
Postpartum Complications
Newborn Complications
Maternal-Newborn Pharmacology
Family-Centered Care and Education
Cultural and Ethical Considerations in Maternal-Newborn Nursing
Introduction
This examination evaluates nursing knowledge and clinical
judgment essential for safe, evidence-based care of postpartum
women and newborns. The test assesses comprehension of normal
physiologic changes during the postpartum period, newborn
adaptation to extrauterine life, and early identification of
complications requiring intervention. Questions integrate
foundational maternal-newborn theory with applied clinical
scenarios emphasizing assessment, prioritization, and family-
centered decision-making. The multiple-choice and scenario-based
structure reflects real-world nursing practice, requiring critical
thinking about patient safety, cultural sensitivity, and
interdisciplinary collaboration. Candidates must demonstrate the
ability to analyze assessment data, implement appropriate nursing
,interventions, and evaluate maternal and neonatal outcomes across
diverse clinical situations.
SECTION ONE: QUESTIONS 1–100
Question 1
A postpartum nurse is assessing a client 2 hours after a
spontaneous vaginal delivery. The fundus is firm, midline, and at
the level of the umbilicus. Which action should the nurse take
next?
A. Massage the fundus vigorously
B. Document the finding as normal
C. Notify the healthcare provider immediately
D. Administer methylergonovine
🟢 B. Document the finding as normal
🔴 RATIONALE: A firm, midline fundus at the level of the
umbilicus is an expected finding 2 hours postpartum. No
intervention is required; the nurse should document and continue
routine monitoring.
Question 2
A nurse is caring for a postpartum client who is 24 hours post-
cesarean birth. The client reports severe abdominal pain
,unrelieved by prescribed analgesics. Which assessment should the
nurse perform first?
A. Assess the incision site
B. Auscultate bowel sounds
C. Obtain a urine specimen
D. Assess vital signs and fundal height
🟢 D. Assess vital signs and fundal height
🔴 RATIONALE: Severe unrelieved pain after cesarean birth may
indicate complications such as uterine atony, hemorrhage, or
hematoma. Vital signs and fundal assessment provide immediate
data on potential life-threatening complications.
Question 3
A newborn is delivered at 39 weeks gestation. At 1 minute of life,
the newborn has a heart rate of 120 beats per minute, a weak cry,
some flexion of extremities, a grimace with stimulation, and a pink
body with blue extremities. What is the APGAR score?
A. 5
B. 6
C. 7
D. 8
🟢 C. 7
🔴 RATIONALE: Heart rate 120 = 2 points; weak cry = 1 point;
some flexion = 1 point; grimace = 1 point; acrocyanosis = 1 point.
Total = 6. However, with a heart rate above 100 and active motion,
the score is 7. Correct calculation: HR 2, respiratory 1, muscle tone
, 1, reflex 1, color 1 = 6. The answer is 6, but if cry is strong, it
would be 7. Based on weak cry, score is 6. The correct APGAR is 6.
Question 4
A postpartum client is receiving magnesium sulfate for
preeclampsia. Which finding requires immediate intervention?
A. Serum magnesium level of 5.5 mg/dL
B. Deep tendon reflexes of 2+
C. Respiratory rate of 11 breaths per minute with absent reflexes
D. Urine output of 40 mL/hour
🟢 C. Respiratory rate of 11 breaths per minute with absent
reflexes
🔴 RATIONALE: Magnesium toxicity manifests as loss of deep
tendon reflexes, respiratory depression (rate below 12), and
oliguria. This finding requires immediate discontinuation of
magnesium sulfate and administration of calcium gluconate.
Question 5
A nurse is teaching a postpartum client about breastfeeding.
Which statement by the client indicates understanding?
A. "I should feed my baby every 4 hours to establish a schedule."
B. "I should feed my baby on demand, typically 8 to 12 times in 24
hours."
C. "I should give formula supplements between feedings."
D. "I should limit feeding time to 10 minutes per breast."
QUESTIONS AND CORRECT ANSWERS
(VERIFIED ANSWERS) PLUS RATIONALES
2026 Q&A | INSTANT DOWNLOAD PDF
Core Domains
Postpartum Assessment and Nursing Care
Newborn Assessment and Transition
Lactation and Infant Feeding
Postpartum Complications
Newborn Complications
Maternal-Newborn Pharmacology
Family-Centered Care and Education
Cultural and Ethical Considerations in Maternal-Newborn Nursing
Introduction
This examination evaluates nursing knowledge and clinical
judgment essential for safe, evidence-based care of postpartum
women and newborns. The test assesses comprehension of normal
physiologic changes during the postpartum period, newborn
adaptation to extrauterine life, and early identification of
complications requiring intervention. Questions integrate
foundational maternal-newborn theory with applied clinical
scenarios emphasizing assessment, prioritization, and family-
centered decision-making. The multiple-choice and scenario-based
structure reflects real-world nursing practice, requiring critical
thinking about patient safety, cultural sensitivity, and
interdisciplinary collaboration. Candidates must demonstrate the
ability to analyze assessment data, implement appropriate nursing
,interventions, and evaluate maternal and neonatal outcomes across
diverse clinical situations.
SECTION ONE: QUESTIONS 1–100
Question 1
A postpartum nurse is assessing a client 2 hours after a
spontaneous vaginal delivery. The fundus is firm, midline, and at
the level of the umbilicus. Which action should the nurse take
next?
A. Massage the fundus vigorously
B. Document the finding as normal
C. Notify the healthcare provider immediately
D. Administer methylergonovine
🟢 B. Document the finding as normal
🔴 RATIONALE: A firm, midline fundus at the level of the
umbilicus is an expected finding 2 hours postpartum. No
intervention is required; the nurse should document and continue
routine monitoring.
Question 2
A nurse is caring for a postpartum client who is 24 hours post-
cesarean birth. The client reports severe abdominal pain
,unrelieved by prescribed analgesics. Which assessment should the
nurse perform first?
A. Assess the incision site
B. Auscultate bowel sounds
C. Obtain a urine specimen
D. Assess vital signs and fundal height
🟢 D. Assess vital signs and fundal height
🔴 RATIONALE: Severe unrelieved pain after cesarean birth may
indicate complications such as uterine atony, hemorrhage, or
hematoma. Vital signs and fundal assessment provide immediate
data on potential life-threatening complications.
Question 3
A newborn is delivered at 39 weeks gestation. At 1 minute of life,
the newborn has a heart rate of 120 beats per minute, a weak cry,
some flexion of extremities, a grimace with stimulation, and a pink
body with blue extremities. What is the APGAR score?
A. 5
B. 6
C. 7
D. 8
🟢 C. 7
🔴 RATIONALE: Heart rate 120 = 2 points; weak cry = 1 point;
some flexion = 1 point; grimace = 1 point; acrocyanosis = 1 point.
Total = 6. However, with a heart rate above 100 and active motion,
the score is 7. Correct calculation: HR 2, respiratory 1, muscle tone
, 1, reflex 1, color 1 = 6. The answer is 6, but if cry is strong, it
would be 7. Based on weak cry, score is 6. The correct APGAR is 6.
Question 4
A postpartum client is receiving magnesium sulfate for
preeclampsia. Which finding requires immediate intervention?
A. Serum magnesium level of 5.5 mg/dL
B. Deep tendon reflexes of 2+
C. Respiratory rate of 11 breaths per minute with absent reflexes
D. Urine output of 40 mL/hour
🟢 C. Respiratory rate of 11 breaths per minute with absent
reflexes
🔴 RATIONALE: Magnesium toxicity manifests as loss of deep
tendon reflexes, respiratory depression (rate below 12), and
oliguria. This finding requires immediate discontinuation of
magnesium sulfate and administration of calcium gluconate.
Question 5
A nurse is teaching a postpartum client about breastfeeding.
Which statement by the client indicates understanding?
A. "I should feed my baby every 4 hours to establish a schedule."
B. "I should feed my baby on demand, typically 8 to 12 times in 24
hours."
C. "I should give formula supplements between feedings."
D. "I should limit feeding time to 10 minutes per breast."
