NURS 306 Quiz 8 V3 | 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 of the midline. What is the priority nursing action?
A. Assist the client to the bathroom to void.
B. Massage the fundus until firm.
C. Administer 10 units of oxytocin IM.
D. Notify the healthcare provider immediately.
Answer: A
Rationale: A fundus that is displaced to the right usually indicates a full bladder, which
prevents the uterus from contracting effectively. Assisting the client to void allows the
uterus to return to the midline and remain firm, reducing the risk of hemorrhage. If the
fundus remains boggy after voiding, then massage and pharmacological interventions
would be appropriate.
2. A nurse is caring for a client who is 4 hours postpartum and reports saturated perineal pads
every 15 minutes. Which medication should the nurse anticipate administering first?
A. Magnesium sulfate
B. Oxytocin
,C. Terbutaline
D. Nifedipine
Answer: B
Rationale: Oxytocin is the first-line medication used to manage postpartum hemorrhage
by promoting uterine contractions. Saturating a pad every 15 minutes indicates excessive
bleeding that requires immediate intervention to prevent hypovolemic shock. Other
medications like Methylergonovine or Carboprost may be used if oxytocin is ineffective, but
oxytocin is always the initial choice.
3. Which of the following is a contraindication for the administration of Methylergonovine
(Methergine) in a postpartum client?
A. Asthma
B. Diabetes mellitus
C. Hypertension
D. Hypothyroidism
Answer: C
Rationale: Methylergonovine is an ergot alkaloid that causes vasoconstriction and uterine
contraction. Because it can significantly increase blood pressure, it is strictly
contraindicated in clients with pre-eclampsia, eclampsia, or chronic hypertension. Nurses
must check the client’s blood pressure prior to administration to ensure patient safety.
, 4. A nurse is assessing a newborn 1 minute after birth. The newborn has a heart rate of
110/min, a slow/irregular respiratory effort, some flexion of extremities, a grimace when
stimulated, and a pink body with blue extremities. What is the APGAR score?
A. 5
B. 8
C. 7
D. 6
Answer: D
Rationale: The score is calculated as follows: HR >100 (2 points), slow/irregular
respirations (1 point), some flexion (1 point), grimace (1 point), and acrocyanosis (1 point).
Adding these together results in a total APGAR score of 6. This score suggests that the
newborn may require some resuscitation efforts or close observation.
5. A nurse is providing discharge teaching to a mother who is breastfeeding. Which statement
by the mother indicates an understanding of mastitis prevention?
A. I will ensure my baby latches onto both the nipple and the areola.
B. I will limit breastfeeding to 5 minutes on each side to prevent nipple cracking.
C. I should wear a tight-fitting underwire bra to support my breasts.
D. I should wash my nipples with soap and water after every feeding.
Answer: A
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 of the midline. What is the priority nursing action?
A. Assist the client to the bathroom to void.
B. Massage the fundus until firm.
C. Administer 10 units of oxytocin IM.
D. Notify the healthcare provider immediately.
Answer: A
Rationale: A fundus that is displaced to the right usually indicates a full bladder, which
prevents the uterus from contracting effectively. Assisting the client to void allows the
uterus to return to the midline and remain firm, reducing the risk of hemorrhage. If the
fundus remains boggy after voiding, then massage and pharmacological interventions
would be appropriate.
2. A nurse is caring for a client who is 4 hours postpartum and reports saturated perineal pads
every 15 minutes. Which medication should the nurse anticipate administering first?
A. Magnesium sulfate
B. Oxytocin
,C. Terbutaline
D. Nifedipine
Answer: B
Rationale: Oxytocin is the first-line medication used to manage postpartum hemorrhage
by promoting uterine contractions. Saturating a pad every 15 minutes indicates excessive
bleeding that requires immediate intervention to prevent hypovolemic shock. Other
medications like Methylergonovine or Carboprost may be used if oxytocin is ineffective, but
oxytocin is always the initial choice.
3. Which of the following is a contraindication for the administration of Methylergonovine
(Methergine) in a postpartum client?
A. Asthma
B. Diabetes mellitus
C. Hypertension
D. Hypothyroidism
Answer: C
Rationale: Methylergonovine is an ergot alkaloid that causes vasoconstriction and uterine
contraction. Because it can significantly increase blood pressure, it is strictly
contraindicated in clients with pre-eclampsia, eclampsia, or chronic hypertension. Nurses
must check the client’s blood pressure prior to administration to ensure patient safety.
, 4. A nurse is assessing a newborn 1 minute after birth. The newborn has a heart rate of
110/min, a slow/irregular respiratory effort, some flexion of extremities, a grimace when
stimulated, and a pink body with blue extremities. What is the APGAR score?
A. 5
B. 8
C. 7
D. 6
Answer: D
Rationale: The score is calculated as follows: HR >100 (2 points), slow/irregular
respirations (1 point), some flexion (1 point), grimace (1 point), and acrocyanosis (1 point).
Adding these together results in a total APGAR score of 6. This score suggests that the
newborn may require some resuscitation efforts or close observation.
5. A nurse is providing discharge teaching to a mother who is breastfeeding. Which statement
by the mother indicates an understanding of mastitis prevention?
A. I will ensure my baby latches onto both the nipple and the areola.
B. I will limit breastfeeding to 5 minutes on each side to prevent nipple cracking.
C. I should wear a tight-fitting underwire bra to support my breasts.
D. I should wash my nipples with soap and water after every feeding.
Answer: A
