NUR 231
EXAM 2
Maternal Nursing
50 Actual Questions w/Correct Answers
Galen College of Nursing
What you Will Get:
• 50 verified questions
• Correct answers with Rationales.
• Ideal for exam preparation and concept
reinforcement.
,1. The nurse is teaching a client with Diabetes Mellitus (Type 1) who just
delivered a healthy baby. Which of the following information should the nurse
include in the client's teaching?
A. Change to oral hypoglycemia medications that will control sugar levels better
than insulin
B. Urine should be checked for ketones every time the client voids
C. Due to hormonal changes after delivery, the need for insulin may decrease
D. Feed the baby formula since insulin received through breastfeeding may cause
low sugar
Correct Answer: C
Expert Rationale:
Postpartum hormonal shifts can reduce insulin resistance, leading to a decreased
requirement for exogenous insulin. Clients should be educated about this change
to avoid hypoglycemia and maintain appropriate glycemic control. Oral
hypoglycemics are not typically used in Type 1 diabetes, and insulin does not pass
into breast milk in amounts that would harm the infant.
2. The nurse is caring for the following clients in the postpartum unit. Which
client should the nurse see first?
A. Multipara mother who has saturated 2 perineal pads in one hour
B. Primipara mother who delivered 3 hours ago and is having difficulty getting the
baby to latch on to the breast
C. Primipara mother requesting help with repositioning her baby to decrease
incisional pain from a cesarean delivery
D. Multipara mother who delivered 16 hours ago and is experiencing abdominal
cramping and sweating
Correct Answer: A
Expert Rationale:
Saturation of two perineal pads within one hour indicates possible postpartum
,hemorrhage, a potentially life-threatening complication requiring immediate
assessment and intervention. This takes priority over breastfeeding difficulties,
positioning discomfort, or expected afterpains.
3. The nurse is assigned clients who delivered within the last 24 hours and just
received the change of shift report. Which of the following clients should the
nurse assess first?
A. The client who reports discomfort in the perineal area from an episiotomy
B. The client who has a temperature of 100.3°F orally
C. The client who reports passing a dime-sized clot with the last void
D. The client who has changes in pulse from 76 to 100
Correct Answer: D
Expert Rationale:
Tachycardia, especially when correlated with recent postpartum status, may
suggest early signs of hemorrhage or infection, necessitating urgent assessment. A
dime-sized clot can be normal, and mild perineal discomfort or a low-grade fever
are not immediately life-threatening.
4. The nurse is caring for a client who gave birth 18 hours ago. The client reports
that her nipples are getting tender and the baby is not breastfeeding well. Which
of the following responses is appropriate by the nurse?
A. "Apply a small amount of topical breast cream to help with the discomfort"
B. "Make sure to compress the breast so the baby can get an adequate amount of
breast tissue into the mouth."
C. "Wait until the baby is crying to show hunger, then breastfeed to help improve
latching."
D. "Try removing the infant's clothing and putting the baby skin to skin on your
chest."
Correct Answer: D
Expert Rationale:
Early skin-to-skin contact promotes effective breastfeeding by facilitating infant
,rooting and latch-on reflexes, which can reduce nipple tenderness and improve
feeding. This intervention supports bonding and stimulates milk flow, enhancing
successful breastfeeding initiation. Waiting until the baby is crying (C) is too late
and can worsen latching difficulties.
5. The nurse is caring for a client who is 1 hour postpartum and observes a
moderate amount of lochia rubra and several small clots on the client's perineal
pad. The fundus is midline and firm at the umbilicus. Which of the following
actions should the nurse implement?
A. Notify the PCP
B. Document findings and continue to monitor the client
C. Encourage the client to empty bladder
D. Increase the frequency of the fundal massage
Correct Answer: B
Expert Rationale:
Moderate lochia rubra with small clots, along with a firm, midline fundus at the
umbilicus within the first hour post-delivery, is typical. Therefore, documenting
and ongoing monitoring are appropriate. Fundal massage or other interventions
are unnecessary unless the fundus becomes boggy or displaced.
6. The nurse is caring for a formula-feeding postpartum client who reports
painful swollen breasts on her third postpartum day. The nurse should
encourage the mother to
A. Gently massage the breasts
B. Refrain from expelling milk
C. Place lettuce leaves on the breasts
D. Stimulate the nipple manually
Correct Answer: B
Expert Rationale:
In formula-feeding mothers, breast engorgement occurs due to milk production
without removal. Encouraging the mother to refrain from expressing milk
, facilitates natural involution and decreases engorgement symptoms. Stimulating
the nipple or massaging can stimulate further milk production, prolonging
discomfort.
7. The nurse is assessing a client who is 24 hours postpartum. Which of the
following findings is most important for the nurse to follow up?
A. Voided 2125 mL of clear yellow urine in the last 24 hours
B. Fundus is slightly firm
C. White blood cell count of 8.5 mm
D. Perineal pad saturated
Correct Answer: D
Expert Rationale:
Saturated perineal pads may indicate ongoing bleeding, which requires immediate
attention to prevent hemorrhagic complications. A WBC of 8.5 is within normal
range, a slightly firm fundus is expected, and increased urine output is normal
postpartum due to diuresis.
8. The nurse is caring for a client who delivered vaginally 4 hours ago. Her
fundus is right of midline and firm only with massage. What is the priority action
by the nurse?
A. Perform a straight catheterization and massage the fundus until it is firm
B. Perform a bladder scan and notify the PCP of the results
C. Insert an indwelling urethral catheter
D. Place the client's hands in warm water
Correct Answer: D
Expert Rationale:
Placing the client's hands in warm water can stimulate relaxation of the pelvic
muscles and facilitate bladder emptying, which may allow the uterus to return to
midline and firm consistency without invasive procedures. A full bladder is the
most common cause of a displaced, boggy fundus.
EXAM 2
Maternal Nursing
50 Actual Questions w/Correct Answers
Galen College of Nursing
What you Will Get:
• 50 verified questions
• Correct answers with Rationales.
• Ideal for exam preparation and concept
reinforcement.
,1. The nurse is teaching a client with Diabetes Mellitus (Type 1) who just
delivered a healthy baby. Which of the following information should the nurse
include in the client's teaching?
A. Change to oral hypoglycemia medications that will control sugar levels better
than insulin
B. Urine should be checked for ketones every time the client voids
C. Due to hormonal changes after delivery, the need for insulin may decrease
D. Feed the baby formula since insulin received through breastfeeding may cause
low sugar
Correct Answer: C
Expert Rationale:
Postpartum hormonal shifts can reduce insulin resistance, leading to a decreased
requirement for exogenous insulin. Clients should be educated about this change
to avoid hypoglycemia and maintain appropriate glycemic control. Oral
hypoglycemics are not typically used in Type 1 diabetes, and insulin does not pass
into breast milk in amounts that would harm the infant.
2. The nurse is caring for the following clients in the postpartum unit. Which
client should the nurse see first?
A. Multipara mother who has saturated 2 perineal pads in one hour
B. Primipara mother who delivered 3 hours ago and is having difficulty getting the
baby to latch on to the breast
C. Primipara mother requesting help with repositioning her baby to decrease
incisional pain from a cesarean delivery
D. Multipara mother who delivered 16 hours ago and is experiencing abdominal
cramping and sweating
Correct Answer: A
Expert Rationale:
Saturation of two perineal pads within one hour indicates possible postpartum
,hemorrhage, a potentially life-threatening complication requiring immediate
assessment and intervention. This takes priority over breastfeeding difficulties,
positioning discomfort, or expected afterpains.
3. The nurse is assigned clients who delivered within the last 24 hours and just
received the change of shift report. Which of the following clients should the
nurse assess first?
A. The client who reports discomfort in the perineal area from an episiotomy
B. The client who has a temperature of 100.3°F orally
C. The client who reports passing a dime-sized clot with the last void
D. The client who has changes in pulse from 76 to 100
Correct Answer: D
Expert Rationale:
Tachycardia, especially when correlated with recent postpartum status, may
suggest early signs of hemorrhage or infection, necessitating urgent assessment. A
dime-sized clot can be normal, and mild perineal discomfort or a low-grade fever
are not immediately life-threatening.
4. The nurse is caring for a client who gave birth 18 hours ago. The client reports
that her nipples are getting tender and the baby is not breastfeeding well. Which
of the following responses is appropriate by the nurse?
A. "Apply a small amount of topical breast cream to help with the discomfort"
B. "Make sure to compress the breast so the baby can get an adequate amount of
breast tissue into the mouth."
C. "Wait until the baby is crying to show hunger, then breastfeed to help improve
latching."
D. "Try removing the infant's clothing and putting the baby skin to skin on your
chest."
Correct Answer: D
Expert Rationale:
Early skin-to-skin contact promotes effective breastfeeding by facilitating infant
,rooting and latch-on reflexes, which can reduce nipple tenderness and improve
feeding. This intervention supports bonding and stimulates milk flow, enhancing
successful breastfeeding initiation. Waiting until the baby is crying (C) is too late
and can worsen latching difficulties.
5. The nurse is caring for a client who is 1 hour postpartum and observes a
moderate amount of lochia rubra and several small clots on the client's perineal
pad. The fundus is midline and firm at the umbilicus. Which of the following
actions should the nurse implement?
A. Notify the PCP
B. Document findings and continue to monitor the client
C. Encourage the client to empty bladder
D. Increase the frequency of the fundal massage
Correct Answer: B
Expert Rationale:
Moderate lochia rubra with small clots, along with a firm, midline fundus at the
umbilicus within the first hour post-delivery, is typical. Therefore, documenting
and ongoing monitoring are appropriate. Fundal massage or other interventions
are unnecessary unless the fundus becomes boggy or displaced.
6. The nurse is caring for a formula-feeding postpartum client who reports
painful swollen breasts on her third postpartum day. The nurse should
encourage the mother to
A. Gently massage the breasts
B. Refrain from expelling milk
C. Place lettuce leaves on the breasts
D. Stimulate the nipple manually
Correct Answer: B
Expert Rationale:
In formula-feeding mothers, breast engorgement occurs due to milk production
without removal. Encouraging the mother to refrain from expressing milk
, facilitates natural involution and decreases engorgement symptoms. Stimulating
the nipple or massaging can stimulate further milk production, prolonging
discomfort.
7. The nurse is assessing a client who is 24 hours postpartum. Which of the
following findings is most important for the nurse to follow up?
A. Voided 2125 mL of clear yellow urine in the last 24 hours
B. Fundus is slightly firm
C. White blood cell count of 8.5 mm
D. Perineal pad saturated
Correct Answer: D
Expert Rationale:
Saturated perineal pads may indicate ongoing bleeding, which requires immediate
attention to prevent hemorrhagic complications. A WBC of 8.5 is within normal
range, a slightly firm fundus is expected, and increased urine output is normal
postpartum due to diuresis.
8. The nurse is caring for a client who delivered vaginally 4 hours ago. Her
fundus is right of midline and firm only with massage. What is the priority action
by the nurse?
A. Perform a straight catheterization and massage the fundus until it is firm
B. Perform a bladder scan and notify the PCP of the results
C. Insert an indwelling urethral catheter
D. Place the client's hands in warm water
Correct Answer: D
Expert Rationale:
Placing the client's hands in warm water can stimulate relaxation of the pelvic
muscles and facilitate bladder emptying, which may allow the uterus to return to
midline and firm consistency without invasive procedures. A full bladder is the
most common cause of a displaced, boggy fundus.
