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NUR 230 Maternal Exam 2 | Galen College of Nursing.
,1. 1.The nurse is assessing physiological changes in a postpartum patient. Which
of the following is the correct order of these physiological changes?
a. Successful feeding → Thermoregulation → Extra-uterine growth →
Spontaneous ovulation
b. Thermoregulation → Successful feeding → Extra-uterine growth →
Spontaneous ovulation
c. Extra-uterine growth → Thermoregulation → Successful feeding →
Spontaneous ovulation
d. Spontaneous ovulation → Thermoregulation → Successful feeding → Extra-
uterine growth
Answer: b. Thermoregulation → Successful feeding → Extra-uterine growth →
Spontaneous ovulation
Rationale: After birth, the newborn first establishes thermoregulation
(maintaining body heat). Next, successful feeding provides nutrition for energy
and growth. Extra-uterine growth (physical development outside the womb)
follows over weeks/months. Spontaneous ovulation occurs much later, typically
after menstruation resumes in the postpartum period (varies, but usually after
several weeks in non-lactating mothers).
2. The nurse is caring for a patient in the immediate postpartum period. Which
of the following is the correct order of nursing interventions?
a. Place a hat on the patient → Utilize a clean cloth to wipe the patient's
perineum
b. Utilize a clean cloth to wipe the patient's perineum → Place a hat on the
patient
Answer: b. Utilize a clean cloth to wipe the patient's perineum → Place a hat on
the patient
Rationale: Perineal care (wiping with a clean cloth) is performed first to maintain
hygiene, prevent infection, and assess bleeding/lacerations after delivery. Placing
,a hat on the patient (to prevent heat loss) follows, as thermoregulation is also
important but hygiene and assessment take priority immediately after birth.
Additional Questions (3–100)
3. A nurse assesses a newborn’s vital signs. Which finding requires immediate
intervention?
a. Heart rate 140 bpm
b. Respiratory rate 30 breaths/min
c. Axillary temperature 36.0°C (96.8°F)
d. Blood pressure 70/45 mmHg
Answer: c (36.0°C is hypothermic; normal newborn temp is 36.5–37.5°C).
Rationale: Hypothermia can lead to respiratory distress, hypoglycemia, and
increased mortality.
4. Which maternal behavior indicates effective bonding with a newborn?
a. Avoiding eye contact
b. Calling the baby by name
c. Asking the nurse to feed the baby
d. Talking on the phone while holding the baby
Answer: b.
Rationale: Naming and eye contact are signs of attachment; avoidance may
indicate postpartum depression or adjustment issues.
5. A postpartum patient reports painful urination and pelvic pressure. What is
the priority action?
a. Offer a warm sitz bath
b. Assess for bladder distention
c. Increase oral fluids
d. Administer analgesics
Answer: b.
Rationale: Bladder distention can displace the uterus, increase bleeding, and
cause pain; assessment comes before interventions.
, 6. Which finding 6 hours after vaginal delivery indicates normal uterine
involution?
a. Fundus at umbilicus, firm
b. Fundus 2 cm above umbilicus, boggy
c. Fundus at symphysis pubis
d. Fundus displaced to the right
Answer: a.
Rationale: Fundus should be at umbilicus and firm; boggy or displaced suggests
atony or full bladder.
7. A nurse teaches a breastfeeding mother. Which statement shows correct
understanding?
a. “I should feed my baby every 4 hours.”
b. “Cracked nipples are normal for the first week.”
c. “I can use both breasts at each feeding.”
d. “Supplementing with water prevents dehydration.”
Answer: c.
Rationale: Feeding from both breasts ensures adequate milk removal and supply;
feeding on demand is preferred.
8. Which lab value in a 1-day-old newborn requires follow-up?
a. Glucose 50 mg/dL
b. Bilirubin 4 mg/dL
c. Hematocrit 55%
d. Platelets 150,000/mcL
Answer: a (normal newborn glucose is 40–60 mg/dL, so 50 is borderline but
acceptable; <40 needs intervention. However, 50 is often fine—this question tests
borderline knowledge. Safer Answer: if glucose <40, intervene. Let’s adjust—
actually 50 is normal. I’ll correct: Choose b? No. Let’s make a better one.)
Correction — better question:
8. Which lab value in a 12-hour-old newborn is most concerning?
a. Glucose 35 mg/dL
b. Bilirubin 3 mg/dL
NUR 230 Maternal Exam 2 | Galen College of Nursing.
,1. 1.The nurse is assessing physiological changes in a postpartum patient. Which
of the following is the correct order of these physiological changes?
a. Successful feeding → Thermoregulation → Extra-uterine growth →
Spontaneous ovulation
b. Thermoregulation → Successful feeding → Extra-uterine growth →
Spontaneous ovulation
c. Extra-uterine growth → Thermoregulation → Successful feeding →
Spontaneous ovulation
d. Spontaneous ovulation → Thermoregulation → Successful feeding → Extra-
uterine growth
Answer: b. Thermoregulation → Successful feeding → Extra-uterine growth →
Spontaneous ovulation
Rationale: After birth, the newborn first establishes thermoregulation
(maintaining body heat). Next, successful feeding provides nutrition for energy
and growth. Extra-uterine growth (physical development outside the womb)
follows over weeks/months. Spontaneous ovulation occurs much later, typically
after menstruation resumes in the postpartum period (varies, but usually after
several weeks in non-lactating mothers).
2. The nurse is caring for a patient in the immediate postpartum period. Which
of the following is the correct order of nursing interventions?
a. Place a hat on the patient → Utilize a clean cloth to wipe the patient's
perineum
b. Utilize a clean cloth to wipe the patient's perineum → Place a hat on the
patient
Answer: b. Utilize a clean cloth to wipe the patient's perineum → Place a hat on
the patient
Rationale: Perineal care (wiping with a clean cloth) is performed first to maintain
hygiene, prevent infection, and assess bleeding/lacerations after delivery. Placing
,a hat on the patient (to prevent heat loss) follows, as thermoregulation is also
important but hygiene and assessment take priority immediately after birth.
Additional Questions (3–100)
3. A nurse assesses a newborn’s vital signs. Which finding requires immediate
intervention?
a. Heart rate 140 bpm
b. Respiratory rate 30 breaths/min
c. Axillary temperature 36.0°C (96.8°F)
d. Blood pressure 70/45 mmHg
Answer: c (36.0°C is hypothermic; normal newborn temp is 36.5–37.5°C).
Rationale: Hypothermia can lead to respiratory distress, hypoglycemia, and
increased mortality.
4. Which maternal behavior indicates effective bonding with a newborn?
a. Avoiding eye contact
b. Calling the baby by name
c. Asking the nurse to feed the baby
d. Talking on the phone while holding the baby
Answer: b.
Rationale: Naming and eye contact are signs of attachment; avoidance may
indicate postpartum depression or adjustment issues.
5. A postpartum patient reports painful urination and pelvic pressure. What is
the priority action?
a. Offer a warm sitz bath
b. Assess for bladder distention
c. Increase oral fluids
d. Administer analgesics
Answer: b.
Rationale: Bladder distention can displace the uterus, increase bleeding, and
cause pain; assessment comes before interventions.
, 6. Which finding 6 hours after vaginal delivery indicates normal uterine
involution?
a. Fundus at umbilicus, firm
b. Fundus 2 cm above umbilicus, boggy
c. Fundus at symphysis pubis
d. Fundus displaced to the right
Answer: a.
Rationale: Fundus should be at umbilicus and firm; boggy or displaced suggests
atony or full bladder.
7. A nurse teaches a breastfeeding mother. Which statement shows correct
understanding?
a. “I should feed my baby every 4 hours.”
b. “Cracked nipples are normal for the first week.”
c. “I can use both breasts at each feeding.”
d. “Supplementing with water prevents dehydration.”
Answer: c.
Rationale: Feeding from both breasts ensures adequate milk removal and supply;
feeding on demand is preferred.
8. Which lab value in a 1-day-old newborn requires follow-up?
a. Glucose 50 mg/dL
b. Bilirubin 4 mg/dL
c. Hematocrit 55%
d. Platelets 150,000/mcL
Answer: a (normal newborn glucose is 40–60 mg/dL, so 50 is borderline but
acceptable; <40 needs intervention. However, 50 is often fine—this question tests
borderline knowledge. Safer Answer: if glucose <40, intervene. Let’s adjust—
actually 50 is normal. I’ll correct: Choose b? No. Let’s make a better one.)
Correction — better question:
8. Which lab value in a 12-hour-old newborn is most concerning?
a. Glucose 35 mg/dL
b. Bilirubin 3 mg/dL
