,NUR254/NUR 254 Exam 2 | Maternal & Pediatric
Nursing | Galen College of Nursing | 26/27|Q&A (PDF)
1. During the immediate newborn transition, the nurse observes a period of reactivity beginning 15
minutes after birth. Which assessment finding is characteristic of this first period of reactivity?
A) Heart rate of 100 to 120 beats per minute and deep sleep
B) Heart rate of 160 to 180 beats per minute and alertness
C) Respiratory rate of 30 to 40 breaths per minute and lethargy
D) Respiratory rate of 70 to 80 breaths per minute and apnea
Correct Answer: Heart rate of 160 to 180 beats per minute and alertness
Rationale: The first period of reactivity occurs 15 to 30 minutes after birth and is characterized by an
increased heart rate (160-180 bpm), alertness, and active movement. The second period of reactivity
occurs 2 to 8 hours later. Deep sleep and lethargy are not typical of this initial reactive period.
2. The nurse is performing a newborn assessment and notes that the infant's toes fan upward when
the sole of the foot is stroked. How should the nurse document this finding?
A) Positive Babinski reflex
B) Positive plantar grasp reflex
C) Positive rooting reflex
D) Positive Moro reflex
Correct Answer: Positive Babinski reflex
Rationale: The Babinski reflex is elicited by stroking the lateral aspect of the sole from heel to toe,
causing the toes to fan upward and curl. This is a normal finding in newborns. The plantar grasp
involves toe curling when pressure is applied to the ball of the foot. Rooting involves turning toward
cheek stimulation, and the Moro is a startle response.
,3. A postpartum client who had a vaginal delivery 2 hours ago has a fundus that is firm, midline, and
at the umbilicus. Lochia is moderate rubra. The client's vital signs are stable. Which action should the
nurse take?
A) Massage the fundus vigorously
B) Document the findings and continue monitoring
C) Notify the provider of possible hemorrhage
D) Administer a prescribed dose of oxytocin
Correct Answer: Document the findings and continue monitoring
Rationale: A firm, midline fundus at the level of the umbilicus with moderate rubra lochia is an
expected finding at 2 hours postpartum. No intervention is needed. Vigorous massage or oxytocin is
indicated only for uterine atony. There is no evidence of hemorrhage, so notification is not required.
4. The nurse is educating a client with Type 1 diabetes who just delivered a healthy newborn. Which
statement should the nurse include regarding postpartum glycemic management?
A) Insulin requirements will increase significantly due to stress
B) Oral hypoglycemic agents are preferred over insulin after delivery
C) Hormonal changes after delivery may decrease the need for insulin
D) Breastfeeding will require supplemental formula to prevent neonatal hypoglycemia
Correct Answer: Hormonal changes after delivery may decrease the need for insulin
Rationale: Postpartum hormonal shifts, particularly the rapid decline in human placental lactogen and
other counterregulatory hormones, reduce insulin resistance. This can lead to a decreased need for
exogenous insulin, placing the client at risk for hypoglycemia. Education on monitoring blood glucose
and adjusting insulin is essential. Oral agents are not typically first-line, and breastfeeding does not
require formula supplementation.
5. The nurse is caring for four postpartum clients. Which client should the nurse assess first?
A) A primipara who delivered 3 hours ago and reports difficulty with breastfeeding latch
B) A multipara who delivered 16 hours ago and reports abdominal cramping and sweating
, C) A primipara requesting assistance with repositioning to reduce cesarean incision pain
D) A multipara who has saturated two perineal pads in the past hour
Correct Answer: A multipara who has saturated two perineal pads in the past hour
Rationale: Saturating two perineal pads in one hour indicates excessive bleeding and possible
postpartum hemorrhage. This client requires immediate assessment and intervention. The other
clients have needs that are important but not life-threatening. Hemorrhage is a leading cause of
maternal morbidity and mortality, making this the priority.
6. The nurse is preparing to assess a postpartum client's fundus. The client's bladder has been
emptied, and the head of the bed is lowered to 30 degrees. Which additional action is essential for
safe fundal assessment?
A) Place one hand over the bladder and use fingertips to locate the fundus
B) Place the hand above the symphysis pubis for support
C) Ask the client to place her hands under her head
D) Place a pillow under the client's lower back
Correct Answer: Place the hand above the symphysis pubis for support
Rationale: Placing a hand above the symphysis pubis provides counterpressure and prevents uterine
prolapse during fundal assessment. This technique enhances safety and comfort. Placing the hand
over the bladder could stimulate voiding but does not provide the necessary support. The other
options do not address the critical safety measure of supporting the lower uterine segment.
7. The nurse is assessing a newborn 24 hours after birth and notes a yellow discoloration of the skin
on the face and chest. The newborn is breastfeeding well and has passed meconium. Which action
should the nurse take?
A) Document the finding as normal physiologic jaundice
B) Notify the provider and prepare for phototherapy
C) Increase the frequency of breastfeeding
D) Obtain an order for a bilirubin level
Nursing | Galen College of Nursing | 26/27|Q&A (PDF)
1. During the immediate newborn transition, the nurse observes a period of reactivity beginning 15
minutes after birth. Which assessment finding is characteristic of this first period of reactivity?
A) Heart rate of 100 to 120 beats per minute and deep sleep
B) Heart rate of 160 to 180 beats per minute and alertness
C) Respiratory rate of 30 to 40 breaths per minute and lethargy
D) Respiratory rate of 70 to 80 breaths per minute and apnea
Correct Answer: Heart rate of 160 to 180 beats per minute and alertness
Rationale: The first period of reactivity occurs 15 to 30 minutes after birth and is characterized by an
increased heart rate (160-180 bpm), alertness, and active movement. The second period of reactivity
occurs 2 to 8 hours later. Deep sleep and lethargy are not typical of this initial reactive period.
2. The nurse is performing a newborn assessment and notes that the infant's toes fan upward when
the sole of the foot is stroked. How should the nurse document this finding?
A) Positive Babinski reflex
B) Positive plantar grasp reflex
C) Positive rooting reflex
D) Positive Moro reflex
Correct Answer: Positive Babinski reflex
Rationale: The Babinski reflex is elicited by stroking the lateral aspect of the sole from heel to toe,
causing the toes to fan upward and curl. This is a normal finding in newborns. The plantar grasp
involves toe curling when pressure is applied to the ball of the foot. Rooting involves turning toward
cheek stimulation, and the Moro is a startle response.
,3. A postpartum client who had a vaginal delivery 2 hours ago has a fundus that is firm, midline, and
at the umbilicus. Lochia is moderate rubra. The client's vital signs are stable. Which action should the
nurse take?
A) Massage the fundus vigorously
B) Document the findings and continue monitoring
C) Notify the provider of possible hemorrhage
D) Administer a prescribed dose of oxytocin
Correct Answer: Document the findings and continue monitoring
Rationale: A firm, midline fundus at the level of the umbilicus with moderate rubra lochia is an
expected finding at 2 hours postpartum. No intervention is needed. Vigorous massage or oxytocin is
indicated only for uterine atony. There is no evidence of hemorrhage, so notification is not required.
4. The nurse is educating a client with Type 1 diabetes who just delivered a healthy newborn. Which
statement should the nurse include regarding postpartum glycemic management?
A) Insulin requirements will increase significantly due to stress
B) Oral hypoglycemic agents are preferred over insulin after delivery
C) Hormonal changes after delivery may decrease the need for insulin
D) Breastfeeding will require supplemental formula to prevent neonatal hypoglycemia
Correct Answer: Hormonal changes after delivery may decrease the need for insulin
Rationale: Postpartum hormonal shifts, particularly the rapid decline in human placental lactogen and
other counterregulatory hormones, reduce insulin resistance. This can lead to a decreased need for
exogenous insulin, placing the client at risk for hypoglycemia. Education on monitoring blood glucose
and adjusting insulin is essential. Oral agents are not typically first-line, and breastfeeding does not
require formula supplementation.
5. The nurse is caring for four postpartum clients. Which client should the nurse assess first?
A) A primipara who delivered 3 hours ago and reports difficulty with breastfeeding latch
B) A multipara who delivered 16 hours ago and reports abdominal cramping and sweating
, C) A primipara requesting assistance with repositioning to reduce cesarean incision pain
D) A multipara who has saturated two perineal pads in the past hour
Correct Answer: A multipara who has saturated two perineal pads in the past hour
Rationale: Saturating two perineal pads in one hour indicates excessive bleeding and possible
postpartum hemorrhage. This client requires immediate assessment and intervention. The other
clients have needs that are important but not life-threatening. Hemorrhage is a leading cause of
maternal morbidity and mortality, making this the priority.
6. The nurse is preparing to assess a postpartum client's fundus. The client's bladder has been
emptied, and the head of the bed is lowered to 30 degrees. Which additional action is essential for
safe fundal assessment?
A) Place one hand over the bladder and use fingertips to locate the fundus
B) Place the hand above the symphysis pubis for support
C) Ask the client to place her hands under her head
D) Place a pillow under the client's lower back
Correct Answer: Place the hand above the symphysis pubis for support
Rationale: Placing a hand above the symphysis pubis provides counterpressure and prevents uterine
prolapse during fundal assessment. This technique enhances safety and comfort. Placing the hand
over the bladder could stimulate voiding but does not provide the necessary support. The other
options do not address the critical safety measure of supporting the lower uterine segment.
7. The nurse is assessing a newborn 24 hours after birth and notes a yellow discoloration of the skin
on the face and chest. The newborn is breastfeeding well and has passed meconium. Which action
should the nurse take?
A) Document the finding as normal physiologic jaundice
B) Notify the provider and prepare for phototherapy
C) Increase the frequency of breastfeeding
D) Obtain an order for a bilirubin level
