Maternal Exam: Maternal and Pediatrics
(NUR 254) | Questions and Answers Latest
Fall - Galen College Of Nursing.
Question 1
A nurse is caring for a client who reports unrelieved episiotomy pain 8 hr following a
vaginal birth. Which of the following actions should the nurse take?
A. Apply an ice pack to the affected area
B. Offer a warm sitz bath
C. Provide a squeeze bottle of antiseptic solution
D. Place a hot pack to the perineum
Correct Answer
A. Apply an ice pack to the affected area
Question 2
A nurse is caring for a newborn and calculating the Apgar score. At 1 min after
delivery, the following findings are noted: heart rate of 110/min; slow, weak cry; some
flexion of extremities; grimace in response to suctioning of the nares; body pink in
color with blue extremities. Calculate the newborn's Apgar score.
Correct Answer
6 points
Question 3
A nurse is caring for a newborn and auscultates an apical heart rate of 130/min.
Which of the following actions should the nurse take?
A. Ask another nurse to verify the heart rate
B. Document this as an expected finding
C. Call the provider to further assess the newborn
D. Prepare the newborn for transport to the NICU
Correct Answer
B. Document this as an expected finding
Page 1 of 138
,Question 4
A nurse is assessing a newborn 1 hr after birth. Which of the following respiratory
rates is within the expected reference range for a newborn?
A. 22/min
B. 48/min
C. 100/min
D. 110/min
Correct Answer
B. 48/min
Question 5
A nurse is caring for a newborn immediately following birth. After assuring a patent
airway, what is the priority nursing action?
A. Administer vitamin K
B. Dry the skin
C. Administer eye prohylaxis
D. Place an identification bracelet
Correct Answer
B. Dry the skin
Question 6
Nurses play a critical role in educating parents regarding measures to prevent infant
abduction. Which instructions contribute to infant safety and security?
A. Because of infant security systems, the baby can be left unattended in the client's
room
B. The mom should request that a second staff member verify the identity of any
questionable person
C. Parents should be told it is safe to posting photographs of their infants on the
internet
D. The baby should be carried in the parent's arms from the room to the nursery
Correct Answer
B. The mom should request that a second staff member verify the identity of any
questionable person
Page 2 of 138
,Question 7
A nurse is reinforcing teaching about reducing perineal infection with a client
following a vaginal delivery. Which of the following should the nurse include in the
teaching? (Select all that apply)
A. Blot the perineal area dry after cleansing
B. Clean the perineal area from front to back
C. Perform hand hygiene before and after voiding
D. Apply ice packs to the perineal area several times daily
E. Wash the perineal area using a squeeze bottle of warm water after each voiding
Correct Answer
A. Blot the perineal area dry after cleansing
B. Clean the perineal area from front to back
C. Perform hand hygiene before and after voiding
E. Wash the perineal area using a squeeze bottle of warm water after each voiding
Question 8
What information should the nurse understand fully regarding either rubella or Rh
status?
A. Breastfeeding mothers cannot be vaccinated with the live attenuated rubella virus
B. Women should be warned that the rubella vaccination is teratogenic and that they
must avoid pregnancy for at least 1 month after vaccination
C. Rh immunoglobulin is safely administered intravenously because it cannot harm a
nursing infant
D. Rh immunoglobulin boosts the immune system and thereby enhances the
effectiveness of vaccinations
Correct Answer
B. Women should be warned that the rubella vaccination is teratogenic and that
they must avoid pregnancy for at least 1 month after vaccination
Page 3 of 138
, Question 9
A nurse is providing teaching about newborn care to a client who is 2 hr postpartum.
Which of the following statements by the client indicates a need for further teaching?
A. "I should keep my baby's head covered."
B. "My baby's temperature will be checked rectally every hour."
C. "I should keep my infant swaddled in a warm blanket."
D. "My baby's bassinet should be kept away from fans and air conditioning."
Correct Answer
B. "My baby's temperature will be checked rectally every hour."
Question 10
A nurse is teaching a newborn's parent to care for the umbilical cord stump. Which of
the following instructions should the nurse include?
A. Wash the cord daily with mild soap and water
B. Cover the cord with the diaper
C. Apply petroleum jelly to the cord stump
D. Give a sponge bath until the cord stump falls off
Correct Answer
D. Give a sponge bath until the cord stump falls off
Question 11
A nurse is caring for a client who is 1 hr postpartum and observes a large 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 take?
A. Document the findings and continue to monitor the client
B. Notify the client's provider
C. Increase the frequency of fundal massage
D. Encourage the client to empty her bladder
Correct Answer
A. Document the findings and continue to monitor the client
Page 4 of 138
(NUR 254) | Questions and Answers Latest
Fall - Galen College Of Nursing.
Question 1
A nurse is caring for a client who reports unrelieved episiotomy pain 8 hr following a
vaginal birth. Which of the following actions should the nurse take?
A. Apply an ice pack to the affected area
B. Offer a warm sitz bath
C. Provide a squeeze bottle of antiseptic solution
D. Place a hot pack to the perineum
Correct Answer
A. Apply an ice pack to the affected area
Question 2
A nurse is caring for a newborn and calculating the Apgar score. At 1 min after
delivery, the following findings are noted: heart rate of 110/min; slow, weak cry; some
flexion of extremities; grimace in response to suctioning of the nares; body pink in
color with blue extremities. Calculate the newborn's Apgar score.
Correct Answer
6 points
Question 3
A nurse is caring for a newborn and auscultates an apical heart rate of 130/min.
Which of the following actions should the nurse take?
A. Ask another nurse to verify the heart rate
B. Document this as an expected finding
C. Call the provider to further assess the newborn
D. Prepare the newborn for transport to the NICU
Correct Answer
B. Document this as an expected finding
Page 1 of 138
,Question 4
A nurse is assessing a newborn 1 hr after birth. Which of the following respiratory
rates is within the expected reference range for a newborn?
A. 22/min
B. 48/min
C. 100/min
D. 110/min
Correct Answer
B. 48/min
Question 5
A nurse is caring for a newborn immediately following birth. After assuring a patent
airway, what is the priority nursing action?
A. Administer vitamin K
B. Dry the skin
C. Administer eye prohylaxis
D. Place an identification bracelet
Correct Answer
B. Dry the skin
Question 6
Nurses play a critical role in educating parents regarding measures to prevent infant
abduction. Which instructions contribute to infant safety and security?
A. Because of infant security systems, the baby can be left unattended in the client's
room
B. The mom should request that a second staff member verify the identity of any
questionable person
C. Parents should be told it is safe to posting photographs of their infants on the
internet
D. The baby should be carried in the parent's arms from the room to the nursery
Correct Answer
B. The mom should request that a second staff member verify the identity of any
questionable person
Page 2 of 138
,Question 7
A nurse is reinforcing teaching about reducing perineal infection with a client
following a vaginal delivery. Which of the following should the nurse include in the
teaching? (Select all that apply)
A. Blot the perineal area dry after cleansing
B. Clean the perineal area from front to back
C. Perform hand hygiene before and after voiding
D. Apply ice packs to the perineal area several times daily
E. Wash the perineal area using a squeeze bottle of warm water after each voiding
Correct Answer
A. Blot the perineal area dry after cleansing
B. Clean the perineal area from front to back
C. Perform hand hygiene before and after voiding
E. Wash the perineal area using a squeeze bottle of warm water after each voiding
Question 8
What information should the nurse understand fully regarding either rubella or Rh
status?
A. Breastfeeding mothers cannot be vaccinated with the live attenuated rubella virus
B. Women should be warned that the rubella vaccination is teratogenic and that they
must avoid pregnancy for at least 1 month after vaccination
C. Rh immunoglobulin is safely administered intravenously because it cannot harm a
nursing infant
D. Rh immunoglobulin boosts the immune system and thereby enhances the
effectiveness of vaccinations
Correct Answer
B. Women should be warned that the rubella vaccination is teratogenic and that
they must avoid pregnancy for at least 1 month after vaccination
Page 3 of 138
, Question 9
A nurse is providing teaching about newborn care to a client who is 2 hr postpartum.
Which of the following statements by the client indicates a need for further teaching?
A. "I should keep my baby's head covered."
B. "My baby's temperature will be checked rectally every hour."
C. "I should keep my infant swaddled in a warm blanket."
D. "My baby's bassinet should be kept away from fans and air conditioning."
Correct Answer
B. "My baby's temperature will be checked rectally every hour."
Question 10
A nurse is teaching a newborn's parent to care for the umbilical cord stump. Which of
the following instructions should the nurse include?
A. Wash the cord daily with mild soap and water
B. Cover the cord with the diaper
C. Apply petroleum jelly to the cord stump
D. Give a sponge bath until the cord stump falls off
Correct Answer
D. Give a sponge bath until the cord stump falls off
Question 11
A nurse is caring for a client who is 1 hr postpartum and observes a large 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 take?
A. Document the findings and continue to monitor the client
B. Notify the client's provider
C. Increase the frequency of fundal massage
D. Encourage the client to empty her bladder
Correct Answer
A. Document the findings and continue to monitor the client
Page 4 of 138
