NURS 306 Quiz 7 V3 | NURS 306 OB |
Actual Q&A with Rationale (NURS306 Quiz
7) | West Coast University
1. A nurse is assessing a client who is 2 hours postpartum. The nurse notes that the fundus is
boggy and displaced to the right of the midline. Which of the following actions should the
nurse take first?
A. Administer oxytocin IV bolus.
B. Assist the client to void.
C. Massage the fundus until firm.
D. Notify the provider of the findings.
Answer: B
Rationale: A displaced fundus to the right of the midline is a classic sign of bladder
distention, which prevents the uterus from contracting effectively. The nurse must assist
the client to empty their bladder to allow the uterus to return to the midline and firm up.
This intervention addresses the underlying cause of the uterine atony in this specific
scenario.
2. A nurse is caring for a newborn immediately following birth. After ensuring a patent
airway, what is the priority nursing action?
A. Dry the newborn thoroughly.
,B. Administer Vitamin K intramuscularly.
C. Apply erythromycin ophthalmic ointment.
D. Assess the newborn’s blood glucose.
Answer: A
Rationale: Drying the newborn is the priority action to prevent heat loss through
evaporation. Newborns are highly susceptible to cold stress, which can lead to metabolic
acidosis and respiratory distress. By drying the infant and removing wet linens, the nurse
promotes thermoregulation and stability.
3. A postpartum client reports pain and tenderness in her left calf. The nurse notes redness
and warmth in the area. Which of the following actions should the nurse take?
A. Massage the affected leg to improve circulation.
B. Elevate the affected leg and notify the provider.
C. Apply a cold compress to the calf.
D. Encourage the client to ambulate frequently.
Answer: B
Rationale: These symptoms are indicative of a Deep Vein Thrombosis (DVT), which is a
serious postpartum complication. Massaging the area or ambulating could dislodge the clot,
leading to a pulmonary embolism. The nurse should elevate the leg to promote venous
return and seek immediate medical evaluation.
, 4. A nurse is evaluating the APGAR score of a newborn at 1 minute. The newborn has a heart
rate of 110/min, a slow/irregular respiratory effort, some flexion of the extremities, a
grimace during suctioning, and a pink body with blue extremities. What is the APGAR score?
A. 5
B. 7
C. 6
D. 8
Answer: C
Rationale: The score is calculated as follows: Heart rate >100 (2 points), slow/irregular
respirations (1 point), some flexion (1 point), grimace (1 point), and acrocyanosis (1 point).
Totaling these values results in a score of 6. This indicates the newborn is having some
difficulty adjusting to extrauterine life and requires close monitoring.
5. A nurse is providing discharge teaching to a client who is breastfeeding. Which of the
following statements by the client indicates an understanding of mastitis?
A. ‘I should stop breastfeeding on the affected side until the infection clears.’
B. ‘Mastitis is caused by wearing a supportive bra.’
C. ‘I should continue to breastfeed frequently to help empty the breast.’
D. ‘I will only need to take antibiotics for two days.’
Answer: C
Actual Q&A with Rationale (NURS306 Quiz
7) | West Coast University
1. A nurse is assessing a client who is 2 hours postpartum. The nurse notes that the fundus is
boggy and displaced to the right of the midline. Which of the following actions should the
nurse take first?
A. Administer oxytocin IV bolus.
B. Assist the client to void.
C. Massage the fundus until firm.
D. Notify the provider of the findings.
Answer: B
Rationale: A displaced fundus to the right of the midline is a classic sign of bladder
distention, which prevents the uterus from contracting effectively. The nurse must assist
the client to empty their bladder to allow the uterus to return to the midline and firm up.
This intervention addresses the underlying cause of the uterine atony in this specific
scenario.
2. A nurse is caring for a newborn immediately following birth. After ensuring a patent
airway, what is the priority nursing action?
A. Dry the newborn thoroughly.
,B. Administer Vitamin K intramuscularly.
C. Apply erythromycin ophthalmic ointment.
D. Assess the newborn’s blood glucose.
Answer: A
Rationale: Drying the newborn is the priority action to prevent heat loss through
evaporation. Newborns are highly susceptible to cold stress, which can lead to metabolic
acidosis and respiratory distress. By drying the infant and removing wet linens, the nurse
promotes thermoregulation and stability.
3. A postpartum client reports pain and tenderness in her left calf. The nurse notes redness
and warmth in the area. Which of the following actions should the nurse take?
A. Massage the affected leg to improve circulation.
B. Elevate the affected leg and notify the provider.
C. Apply a cold compress to the calf.
D. Encourage the client to ambulate frequently.
Answer: B
Rationale: These symptoms are indicative of a Deep Vein Thrombosis (DVT), which is a
serious postpartum complication. Massaging the area or ambulating could dislodge the clot,
leading to a pulmonary embolism. The nurse should elevate the leg to promote venous
return and seek immediate medical evaluation.
, 4. A nurse is evaluating the APGAR score of a newborn at 1 minute. The newborn has a heart
rate of 110/min, a slow/irregular respiratory effort, some flexion of the extremities, a
grimace during suctioning, and a pink body with blue extremities. What is the APGAR score?
A. 5
B. 7
C. 6
D. 8
Answer: C
Rationale: The score is calculated as follows: Heart rate >100 (2 points), slow/irregular
respirations (1 point), some flexion (1 point), grimace (1 point), and acrocyanosis (1 point).
Totaling these values results in a score of 6. This indicates the newborn is having some
difficulty adjusting to extrauterine life and requires close monitoring.
5. A nurse is providing discharge teaching to a client who is breastfeeding. Which of the
following statements by the client indicates an understanding of mastitis?
A. ‘I should stop breastfeeding on the affected side until the infection clears.’
B. ‘Mastitis is caused by wearing a supportive bra.’
C. ‘I should continue to breastfeed frequently to help empty the breast.’
D. ‘I will only need to take antibiotics for two days.’
Answer: C
