NURS 306 Quiz 8 V1 | NURS 306 OB |
Actual Q&A with Rationale (NURS306 Quiz
8) | West Coast University
1. A nurse is assessing a client 1 hr after delivery and notes that the uterus is boggy and
deviated to the right. Which of the following actions should the nurse take first?
A. Assist the client to empty her bladder.
B. Massage the fundus until firm.
C. Administer oxytocin via IV bolus.
D. Notify the primary care provider.
Answer: A
Rationale: A uterus that is boggy and displaced to the right usually indicates a full bladder,
which prevents the uterus from contracting efficiently. Assisting the client to void is the
priority action to allow the uterus to return to the midline and contract. Once the bladder is
empty, the nurse should reassess the fundus and massage if it remains boggy.
2. A nurse is caring for a client who is experiencing a postpartum hemorrhage and has a
prescription for Methylergonovine. Which of the following conditions is a contraindication for
this medication?
A. Asthma
B. Deep vein thrombosis
,C. Hypertension
D. Type 2 Diabetes Mellitus
Answer: C
Rationale: Methylergonovine is an oxytocic agent that causes vasoconstriction to control
postpartum bleeding. Because it can significantly increase blood pressure, it is strictly
contraindicated in clients with hypertension or preeclampsia. The nurse must check the
client’s blood pressure prior to administration to ensure safety.
3. A nurse is assessing a newborn who is 2 hr old. Which of the following findings should the
nurse report to the provider as a sign of respiratory distress?
A. Acrocyanosis
B. Nasal flaring
C. Diaphragmatic breathing
D. Respiratory rate of 50/min
Answer: B
Rationale: Nasal flaring is a clinical sign of respiratory distress as the newborn attempts to
decrease airway resistance. Other signs include intercostal retractions, grunting, and
tachypnea. Acrocyanosis and diaphragmatic breathing are normal findings in a newborn
within the first 24 hours.
, 4. A nurse is caring for a client who has developed mastitis. Which of the following
instructions should the nurse include in the teaching?
A. Stop breastfeeding on the affected side.
B. Apply cold compresses for 20 minutes every hour.
C. Continue to breastfeed or pump frequently.
D. Wear a loose-fitting bra for comfort.
Answer: C
Rationale: Emptying the breast is essential in treating mastitis to prevent the progression
of the infection and the formation of an abscess. The nurse should encourage the client to
continue breastfeeding or use a pump frequently. Proper hand hygiene and completing the
full course of antibiotics are also critical components of care.
5. A nurse is monitoring a newborn who is receiving phototherapy for hyperbilirubinemia.
Which of the following actions should the nurse take?
A. Ensure the newborn’s eyes are covered with an opaque mask.
B. Apply lotion to the newborn’s skin to prevent drying.
C. Limit the newborn’s fluid intake to prevent diarrhea.
D. Keep the newborn in a swaddled position.
Answer: A
Actual Q&A with Rationale (NURS306 Quiz
8) | West Coast University
1. A nurse is assessing a client 1 hr after delivery and notes that the uterus is boggy and
deviated to the right. Which of the following actions should the nurse take first?
A. Assist the client to empty her bladder.
B. Massage the fundus until firm.
C. Administer oxytocin via IV bolus.
D. Notify the primary care provider.
Answer: A
Rationale: A uterus that is boggy and displaced to the right usually indicates a full bladder,
which prevents the uterus from contracting efficiently. Assisting the client to void is the
priority action to allow the uterus to return to the midline and contract. Once the bladder is
empty, the nurse should reassess the fundus and massage if it remains boggy.
2. A nurse is caring for a client who is experiencing a postpartum hemorrhage and has a
prescription for Methylergonovine. Which of the following conditions is a contraindication for
this medication?
A. Asthma
B. Deep vein thrombosis
,C. Hypertension
D. Type 2 Diabetes Mellitus
Answer: C
Rationale: Methylergonovine is an oxytocic agent that causes vasoconstriction to control
postpartum bleeding. Because it can significantly increase blood pressure, it is strictly
contraindicated in clients with hypertension or preeclampsia. The nurse must check the
client’s blood pressure prior to administration to ensure safety.
3. A nurse is assessing a newborn who is 2 hr old. Which of the following findings should the
nurse report to the provider as a sign of respiratory distress?
A. Acrocyanosis
B. Nasal flaring
C. Diaphragmatic breathing
D. Respiratory rate of 50/min
Answer: B
Rationale: Nasal flaring is a clinical sign of respiratory distress as the newborn attempts to
decrease airway resistance. Other signs include intercostal retractions, grunting, and
tachypnea. Acrocyanosis and diaphragmatic breathing are normal findings in a newborn
within the first 24 hours.
, 4. A nurse is caring for a client who has developed mastitis. Which of the following
instructions should the nurse include in the teaching?
A. Stop breastfeeding on the affected side.
B. Apply cold compresses for 20 minutes every hour.
C. Continue to breastfeed or pump frequently.
D. Wear a loose-fitting bra for comfort.
Answer: C
Rationale: Emptying the breast is essential in treating mastitis to prevent the progression
of the infection and the formation of an abscess. The nurse should encourage the client to
continue breastfeeding or use a pump frequently. Proper hand hygiene and completing the
full course of antibiotics are also critical components of care.
5. A nurse is monitoring a newborn who is receiving phototherapy for hyperbilirubinemia.
Which of the following actions should the nurse take?
A. Ensure the newborn’s eyes are covered with an opaque mask.
B. Apply lotion to the newborn’s skin to prevent drying.
C. Limit the newborn’s fluid intake to prevent diarrhea.
D. Keep the newborn in a swaddled position.
Answer: A
