NUR 254 EXAM 50 QUESTIONS AND ANSWERS 2025-GALEN COLLEGE OF NURSING

1.) The nurse is caring for a client who gave birth 18 hours ago. The client reports that her nipples are getting tender and the baby is not breastfeeding well. Which of the following responses is appropriate by the nurse? A. "Apply a small amount of topical breast cream to help with the discomfort" B. "Make sure to compress the breast so the baby can get an adequate mount of breast tissue into the mouth." C. Wait until the baby is crying to show hunger, then breastfeed to help improve latching." D. "Try removing the infant's clothing and putting the baby skin to skin on your chest. D. "Try removing the infant's clothing and putting the baby skin to skin on your chest. 2.) The nurse is caring for a client who is 1 hour postpartum and observes a moderate amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse implement? A. Notify the PCP B. Document findings and continue to monitor the client C. Encouragetheclienttoemptybladder D. Increase the frequency of the fundal massage B. Document findings and continue to monitor the client 3.) The nurse is teaching a client with Diabetes Mellitus (Type 1) who just delivered a healthy baby. Which of the following information should the nurse include in the client's teaching? A. Change to oral hypoglycemia medications that will control sugar levels better than insulin B. Urine should be checked for ketones every time the client voids C. Due to hormonal changes after delivery, the need for insulin may decrease D. Feed the baby formula since insulin received though breastfeeding may cause low sugar. C. Due to hormonal changes after delivery, the need for insulin may decrease The nurse is caring for the following clients in the postpartum unit. Which client should the nurse see first? A. Multipara mother who has saturated 2 perineal pads in one hour B. Primipara mother who delivered 3 hours ago and is having difficulty getting the baby to latch on to the breast C. Primipara mother requesting help with repositioning her baby to decrease incisional pain from a cesarean delivery D. Multipara mother who delivered 16 hours and is experiencing abdominal cramping and sweating. A. Multipara mother who has saturated 2 perineal pads in one hour 5.) The nurse is assigned clients who delivered withing the last 24 hours and just received the change of shift report. Which of the following clients should the nurse assess first? A. The client who reports discomfort in the perineal area from an episiotomy B. The client who has a temp of 100.3F orally C. The client who reports passing a dime sized clot with the last void D. The client who has changes in pulse from 76 to 100 D. The client who has changes in pulse from 76 to 100 6.) The nurse is caring for a formula-feeding postpartum client who reports painful swollen breasts on her third post-partum day. The nurse should encourage the mother to A. Gently massage the breasts B. Refrain from expelling milk C. Place lettuce leaves on the breasts D. Stimulate the nipple manually B. Refrain from expelling milk 7.) The nurse is assessing a client who is 24 hours postpartum. Which of the following findings is most important for the nurse to follow up? A. Voided 2125mL of clear yellow urine in the last 24 hours B. Fundus is slightly firm C. White blood cell count of 8.5mm D. Perineal pad saturated in 4 B. Fundus is slightly firm 8.) The nurse is caring for a client who delivered vaginally 4 hours ago. Her fundus is right of midline and firm only with massage. What is the priority action by the nurse? A. Perform a straight catheterization and massage the fundus until it is firm B. Perform a bladder scan and notify the PCP of the results. C. Insert a indwelling urethral catheter D. Place the client's hands in warm water D. Place the client's hands in warm water 9.) The nurse is preparing to assess a post-partum client's fundus. The nurse should put the head of the bed down to 30 degrees, ensure the client's bladder has been emptied recently and A. Ask the client to place hands under head B. Place a pillow under the client's lower back C. Place one hand over the bladder and use fingertips to locate fundus D. Place hand above symphysis pubis for support D. Place hand above symphysis pubis for support 10.) The nurse is caring for a client who delivered a healthy infant 4 hours ago. The nurse notes that the mother's temperature is 100.2F. Which of the following action is the priority for the nurse? A.Retake the temperature in 15 minutes B. Notify the PCP C.Encourage oral fluids D. Administer prescribed Acetaminophen C.Encourage oral fluids The nurse is providing instructions to a client who is breastfeeding her newborn. Which of the following statements by the client indicates the need for further instructions?"I should. A.Use water and antibacterial soap to clean my nipples"" B. I should breastfeed 8-12 time per day" C. "I should use pillows to help support my baby while at the breast" D."I should make sure the baby latches on well in the beginning" A.Use water and antibacterial soap to clean my nipples"" 12.) The nurse is teaching a post-partum client who has been prescribed Pho(D) immune globulin (RhoGAM) about the purpose of this medication. The nurse determines that teaching is effective if the client states that RhoGAM will protect her next baby from A. Developing Rh antigens B. Being affected by Rh incompatibility C. Developing physiological jaundice D. Having Rh positive blood B. Being affected by Rh incompatibility 13.) The nurse is caring for a client in the 4th stage of labor following a spontaneous vaginal delivery. The medical record indicates an estimated blood loss of 600mL. The client has a hx of HTN. Which medication should the nurse recognize as being contraindicated for this client. A. Methyl prostaglandin B. Oxytocin C. Methylergonovine D. Misoprostol C. Methylergonovine 14.) The nurse is caring for assigned postpartum clients. The nurse recognized that client at highest risk for a post-partum infection is the client who A.Had eclampsia B. Delivered a preterm infant C. Delivered via cesarean birth D. Had a second-degree laceration C. Delivered via cesarean birth 15.) The nurse is caring for a client and notes the following laboratory results on the first day after delivery: WBC count 22,000mm, hemoglobin 13.0 g/dL, and platelets 90,000mm3. Which of the following is a correct interpretation of the client's laboratory values? A.Client is developing a postpartum infection B. Platelets are abnormal and would place the client at risk for postpartum hemorrhage C.Hemoglobin is low but normal for the postpartum client D. Blood bank needs to be notified to send immune globulin human for the client B. Platelets are abnormal and would place the client at risk for postpartum hemorrhage The nurse is caring for a breastfeeding, 4 day post-partum client. The client reports her breasts feel heavy and painful. The nurse should instruct the client to do which of the following before nursing the baby? A.Rub lanolin cream on her breasts B.Feed her baby from a bottle for a few days C.Express a small amount of breast milk D. Apply ice cubes to her nipples C.Express a small amount of breast milk The nurse is caring for a post-partum client and observes heavy lochia rubra. The nurse should first A. Assess maternal BP and Pulse for S/S of hypovolemic shock B. Administered prescribed oxytocin C.Palpate the bladder and have the client void if full D. Call the PCP C.Palpate the bladder and have the client void if full 18.) The nurse is caring for a client who delivered a newborn by normal spontaneous vaginal delivery 24 hours ago. The client has a temperature of 101.0F. The nurse should A.Assess the client's breasts for redness and swelling B.Determine if the client's lochia has a foul smell C. Ask the client if she is experiencing calf pain D. Instruct the client to drink 2-3 glasses of water within the next 24 hours B.Determine if the client's lochia has a foul smell 19.) The nurse is caring for a 15 year old client and her newborn. The client is texting on her phone and ignores her newborn. Which strategy should help facilitate mother-infant attachment for this client? A.Suggest the mother put the phone on vibrate and interact with her newborn B.Arrange for the mother to watch a video on parent-infant interaction C.Demonstrate different positions for holding her infant while feeding D. Show the mother how the infant initiates interaction and pays attention to her D. Show the mother how the infant initiates interaction and pays attention to her The nurse is caring for a postpartum client and her newborn. The nurse observes the newborn crying and the mother picking the newborn up to calm them down. This reflects the client is experiencing A. Mutuality B. Synchrony C. Reciprocity D. Claiming C. Reciprocity The nurse is caring for a postpartum client of Vietnamese descent. The client's husband brings a large container of seaweed soup to the hospital. When the nurse enters the room, the husband asks for help with warming the soup for the client. Which of the following is an appropriate response by the nurse? A."I'll warm the soup in the microwave for you" B."What ingredients are in the soup?" C."Didn't you like your lunch today?" D."is the doctor okay with you eating this soup?" A."I'll warm the soup in the microwave for you"