NR327/NR 327 Exam 3 V3 | Maternal Child Nursing
Q&A with Rationale | Chamberlain University
1. A nurse is assessing a client who is 4 hours postpartum and notes the fundus is firm, 2 cm
above the umbilicus, and deviated to the right. Which of the following actions should the
nurse take first?
A. Administer oxytocin as prescribed.
B. Perform a vigorous fundal massage.
C. Notify the provider of potential hemorrhage.
D. Assist the client to the bathroom to void.
Correct Answer: D
Explanation: A fundus that is displaced to the right and elevated above the umbilicus
typically indicates a distended bladder. A full bladder prevents the uterus from contracting
efficiently, which increases the risk of postpartum hemorrhage. Assisting the client to void
will allow the uterus to return to the midline and contract properly.
2. A nurse is monitoring a newborn who was born at 34 weeks of gestation. Which of the
following findings should the nurse prioritize?
A. Nasal flaring and substernal retractions.
B. Occasional sneezing and hiccuping.
C. Acrocyanosis of the hands and feet.
,D. Sleepiness after a feeding session.
Correct Answer: A
Explanation: Nasal flaring and substernal retractions are classic signs of neonatal
respiratory distress syndrome, which is common in preterm infants due to surfactant
deficiency. The nurse must prioritize respiratory assessment and intervention to ensure
adequate oxygenation. Acrocyanosis and occasional sneezing are considered normal
physiological findings in the early neonatal period.
3. A postpartum nurse is providing discharge teaching to a client who is breastfeeding. Which
statement by the client indicates a need for further teaching?
A. “I will feed my baby whenever he shows hunger cues like rooting.”
B. “I will use a finger to break the suction before removing the baby.”
C. “I need to consume about 500 extra calories a day while nursing.”
D. “I should wash my nipples with soap and water after every feed.”
Correct Answer: D
Explanation: Clients should be taught to avoid using soap on their nipples as it can cause
dryness and cracking, leading to pain and potential infection. Washing with plain water or
applying expressed breast milk is recommended to maintain skin integrity. The other
options reflect correct understanding of breastfeeding practices and nutritional needs.
,4. A nurse is assessing a client who is 2 days postpartum and reports breast engorgement.
Which of the following recommendations is appropriate for a client who is bottle-feeding?
A. Apply warm compresses to the breasts before feedings.
B. Wear a tight-fitting supportive bra continuously.
C. Express small amounts of milk to relieve pressure.
D. Stimulate the nipples frequently to decrease milk production.
Correct Answer: B
Explanation: For a client who is not breastfeeding, the goal is to suppress lactation and
reduce discomfort. Wearing a tight-fitting bra provides support and prevents stimulation
that could trigger more milk production. The nurse should also advise the use of cold
cabbage leaves or ice packs rather than heat or expression.
5. A nurse is evaluating the Apgar score of a newborn at 1 minute of life. The infant has a
heart rate of 110/min, a weak cry, some flexion of the extremities, grimacing when
stimulated, and a pink body with blue extremities. What is the Apgar score?
A. 5
B. 6
C. 7
D. 8
Correct Answer: B
, Explanation: The Apgar score is calculated as follows: Heart rate >100 (2 points), weak
cry/respiratory effort (1 point), some flexion (1 point), grimace (1 point), and acrocyanosis
(1 point). Adding these gives a total score of 6. This indicates that the newborn may require
some resuscitation or close monitoring.
6. Which of the following interventions should the nurse perform to prevent heat loss via
evaporation in a newborn?
A. Place the newborn on a pre-warmed radiant warmer.
B. Keep the newborn’s crib away from air conditioning vents.
C. Dry the newborn thoroughly immediately after birth.
D. Ensure the stethoscope is warmed before touching the skin.
Correct Answer: C
Explanation: Evaporative heat loss occurs when moisture on the skin is converted to
vapor, taking body heat with it. Drying the infant immediately after birth is the primary
nursing action to prevent this specific type of heat loss. Other methods like using a warmer
prevent radiation or conduction losses, while avoiding vents prevents convection loss.
7. A nurse is caring for a client who is 12 hours postpartum following a vaginal delivery. The
nurse notes the lochia is dark red and contains several small clots. How should the nurse
document this finding?
A. Lochia serosa
B. Lochia rubra
Q&A with Rationale | Chamberlain University
1. A nurse is assessing a client who is 4 hours postpartum and notes the fundus is firm, 2 cm
above the umbilicus, and deviated to the right. Which of the following actions should the
nurse take first?
A. Administer oxytocin as prescribed.
B. Perform a vigorous fundal massage.
C. Notify the provider of potential hemorrhage.
D. Assist the client to the bathroom to void.
Correct Answer: D
Explanation: A fundus that is displaced to the right and elevated above the umbilicus
typically indicates a distended bladder. A full bladder prevents the uterus from contracting
efficiently, which increases the risk of postpartum hemorrhage. Assisting the client to void
will allow the uterus to return to the midline and contract properly.
2. A nurse is monitoring a newborn who was born at 34 weeks of gestation. Which of the
following findings should the nurse prioritize?
A. Nasal flaring and substernal retractions.
B. Occasional sneezing and hiccuping.
C. Acrocyanosis of the hands and feet.
,D. Sleepiness after a feeding session.
Correct Answer: A
Explanation: Nasal flaring and substernal retractions are classic signs of neonatal
respiratory distress syndrome, which is common in preterm infants due to surfactant
deficiency. The nurse must prioritize respiratory assessment and intervention to ensure
adequate oxygenation. Acrocyanosis and occasional sneezing are considered normal
physiological findings in the early neonatal period.
3. A postpartum nurse is providing discharge teaching to a client who is breastfeeding. Which
statement by the client indicates a need for further teaching?
A. “I will feed my baby whenever he shows hunger cues like rooting.”
B. “I will use a finger to break the suction before removing the baby.”
C. “I need to consume about 500 extra calories a day while nursing.”
D. “I should wash my nipples with soap and water after every feed.”
Correct Answer: D
Explanation: Clients should be taught to avoid using soap on their nipples as it can cause
dryness and cracking, leading to pain and potential infection. Washing with plain water or
applying expressed breast milk is recommended to maintain skin integrity. The other
options reflect correct understanding of breastfeeding practices and nutritional needs.
,4. A nurse is assessing a client who is 2 days postpartum and reports breast engorgement.
Which of the following recommendations is appropriate for a client who is bottle-feeding?
A. Apply warm compresses to the breasts before feedings.
B. Wear a tight-fitting supportive bra continuously.
C. Express small amounts of milk to relieve pressure.
D. Stimulate the nipples frequently to decrease milk production.
Correct Answer: B
Explanation: For a client who is not breastfeeding, the goal is to suppress lactation and
reduce discomfort. Wearing a tight-fitting bra provides support and prevents stimulation
that could trigger more milk production. The nurse should also advise the use of cold
cabbage leaves or ice packs rather than heat or expression.
5. A nurse is evaluating the Apgar score of a newborn at 1 minute of life. The infant has a
heart rate of 110/min, a weak cry, some flexion of the extremities, grimacing when
stimulated, and a pink body with blue extremities. What is the Apgar score?
A. 5
B. 6
C. 7
D. 8
Correct Answer: B
, Explanation: The Apgar score is calculated as follows: Heart rate >100 (2 points), weak
cry/respiratory effort (1 point), some flexion (1 point), grimace (1 point), and acrocyanosis
(1 point). Adding these gives a total score of 6. This indicates that the newborn may require
some resuscitation or close monitoring.
6. Which of the following interventions should the nurse perform to prevent heat loss via
evaporation in a newborn?
A. Place the newborn on a pre-warmed radiant warmer.
B. Keep the newborn’s crib away from air conditioning vents.
C. Dry the newborn thoroughly immediately after birth.
D. Ensure the stethoscope is warmed before touching the skin.
Correct Answer: C
Explanation: Evaporative heat loss occurs when moisture on the skin is converted to
vapor, taking body heat with it. Drying the infant immediately after birth is the primary
nursing action to prevent this specific type of heat loss. Other methods like using a warmer
prevent radiation or conduction losses, while avoiding vents prevents convection loss.
7. A nurse is caring for a client who is 12 hours postpartum following a vaginal delivery. The
nurse notes the lochia is dark red and contains several small clots. How should the nurse
document this finding?
A. Lochia serosa
B. Lochia rubra
