NURS 306 Quiz 8 V2 | NURS 306 OB |
Actual Q&A with Rationale (NURS306 Quiz
8) | West Coast University
1. A nurse is assessing a postpartum client 2 hours after delivery and notes the fundus is
boggy and displaced to the right. What is the priority nursing action?
A. Massage the fundus until firm.
B. Notify the primary care provider immediately.
C. Administer oxytocin as prescribed.
D. Assist the client to the bathroom to void.
Answer: D
Rationale: A fundus that is displaced to the right and boggy typically indicates a distended
bladder, which prevents the uterus from contracting effectively. Assisting the client to
empty their bladder is the first priority to allow the uterus to return to the midline and firm
up. Once the bladder is empty, the nurse can then reassess and massage the fundus if it
remains boggy.
2. A nurse is teaching a postpartum client about the different types of lochia. Which
description should the nurse include for lochia serosa?
A. Bright red discharge lasting for the first 3 days.
B. Pinkish-brown discharge lasting from day 4 to day 10.
,C. Yellowish-white discharge lasting from day 11 to 6 weeks.
D. Bloody discharge with small clots.
Answer: B
Rationale: Lochia serosa is the second stage of postpartum vaginal discharge,
characterized by its pinkish-brown color. It typically occurs from approximately day 4 to
day 10 after delivery and consists of serosanguineous exudate and cervical mucus.
Understanding the normal progression of lochia is essential for the nurse to identify
potential complications such as hemorrhage or infection.
3. A client who is breastfeeding complains of a painful, reddened area on one breast, fever,
and chills. Which condition should the nurse suspect?
A. Candidiasis of the nipple
B. Engorgement
C. Plugged milk duct
D. Mastitis
Answer: D
Rationale: Mastitis is an infection of the breast tissue that often presents with localized
pain, redness, warmth, and systemic symptoms like fever and chills. It is most common in
breastfeeding women and usually requires antibiotic treatment. The nurse should
encourage the mother to continue breastfeeding or pumping to ensure the breast is
emptied frequently.
, 4. A nurse is caring for a client receiving magnesium sulfate for preeclampsia. Which finding is
the earliest sign of magnesium toxicity?
A. Loss of deep tendon reflexes (DTRs).
B. Respiratory rate of 10 breaths per minute.
C. Decreased urinary output.
D. Altered level of consciousness.
Answer: A
Rationale: The loss of deep tendon reflexes is typically the first clinical sign of magnesium
sulfate toxicity. Magnesium sulfate acts as a central nervous system depressant, and as
levels rise, reflexes become diminished before more severe respiratory and cardiac
depression occurs. Nurses must monitor DTRs, respiratory rate, and urinary output closely
when administering this medication.
5. A newborn has an Apgar score of 9 at 1 minute and 9 at 5 minutes. How should the nurse
interpret these findings?
A. The newborn is in severe distress.
B. The newborn is adjusting well to extrauterine life.
C. The newborn requires immediate resuscitation.
D. The newborn has moderate difficulty transitioning.
Answer: B
Actual Q&A with Rationale (NURS306 Quiz
8) | West Coast University
1. A nurse is assessing a postpartum client 2 hours after delivery and notes the fundus is
boggy and displaced to the right. What is the priority nursing action?
A. Massage the fundus until firm.
B. Notify the primary care provider immediately.
C. Administer oxytocin as prescribed.
D. Assist the client to the bathroom to void.
Answer: D
Rationale: A fundus that is displaced to the right and boggy typically indicates a distended
bladder, which prevents the uterus from contracting effectively. Assisting the client to
empty their bladder is the first priority to allow the uterus to return to the midline and firm
up. Once the bladder is empty, the nurse can then reassess and massage the fundus if it
remains boggy.
2. A nurse is teaching a postpartum client about the different types of lochia. Which
description should the nurse include for lochia serosa?
A. Bright red discharge lasting for the first 3 days.
B. Pinkish-brown discharge lasting from day 4 to day 10.
,C. Yellowish-white discharge lasting from day 11 to 6 weeks.
D. Bloody discharge with small clots.
Answer: B
Rationale: Lochia serosa is the second stage of postpartum vaginal discharge,
characterized by its pinkish-brown color. It typically occurs from approximately day 4 to
day 10 after delivery and consists of serosanguineous exudate and cervical mucus.
Understanding the normal progression of lochia is essential for the nurse to identify
potential complications such as hemorrhage or infection.
3. A client who is breastfeeding complains of a painful, reddened area on one breast, fever,
and chills. Which condition should the nurse suspect?
A. Candidiasis of the nipple
B. Engorgement
C. Plugged milk duct
D. Mastitis
Answer: D
Rationale: Mastitis is an infection of the breast tissue that often presents with localized
pain, redness, warmth, and systemic symptoms like fever and chills. It is most common in
breastfeeding women and usually requires antibiotic treatment. The nurse should
encourage the mother to continue breastfeeding or pumping to ensure the breast is
emptied frequently.
, 4. A nurse is caring for a client receiving magnesium sulfate for preeclampsia. Which finding is
the earliest sign of magnesium toxicity?
A. Loss of deep tendon reflexes (DTRs).
B. Respiratory rate of 10 breaths per minute.
C. Decreased urinary output.
D. Altered level of consciousness.
Answer: A
Rationale: The loss of deep tendon reflexes is typically the first clinical sign of magnesium
sulfate toxicity. Magnesium sulfate acts as a central nervous system depressant, and as
levels rise, reflexes become diminished before more severe respiratory and cardiac
depression occurs. Nurses must monitor DTRs, respiratory rate, and urinary output closely
when administering this medication.
5. A newborn has an Apgar score of 9 at 1 minute and 9 at 5 minutes. How should the nurse
interpret these findings?
A. The newborn is in severe distress.
B. The newborn is adjusting well to extrauterine life.
C. The newborn requires immediate resuscitation.
D. The newborn has moderate difficulty transitioning.
Answer: B
