NUR 231 Exam 4 – Maternal Nursing Comprehensive Review 2026 UPDATE
1. A nurse is assessing a client who is 2 hours postpartum and observes that the fundus is
displaced to the right and above the umbilicus. What is the priority nursing action?
A. Massage the fundus immediately.
B. Administer oxytocin as ordered.
C. Assist the client to the bathroom to void.
D. Notify the provider of a potential hemorrhage.
Answer: C
Rationale: A fundus that is displaced to the right and above the umbilicus is a classic sign
of a full bladder, which can prevent the uterus from contracting effectively and lead to
hemorrhage.
2. Which of the following describes lochia serosa?
A. Pinkish-brown discharge lasting from day 4 to day 10 postpartum.
B. Bright red discharge lasting 1-3 days postpartum.
C. Yellow-white discharge lasting from day 11 to 6 weeks postpartum.
D. Bloody discharge containing small clots and decidua.
Answer: A
,Rationale: Lochia serosa is the second stage of postpartum discharge, appearing pinkish-
brown and typically lasting from the 4th to the 10th day after delivery.
3. A newborn is being assessed at 1 minute of life. The heart rate is 110, there is a weak cry,
some flexion of extremities, the body is pink with blue hands and feet, and the infant
grimaces when suctioned. What is the APGAR score?
A. 6
B. 8
C. 7
D. 9
Answer: C
Rationale: Heart rate > 100 (2), Weak cry (1), Some flexion (1), Acrocyanosis (1), Grimace
(2) = 7.
4. Which medication is standardly administered to newborns within 1 hour of birth to
prevent ophthalmia neonatorum?
A. Vitamin K (Phytonadione)
B. Hepatitis B vaccine
C. Triple dye
D. Erythromycin ophthalmic ointment
Answer: D
, Rationale: Erythromycin ointment is applied to the newborn’s eyes to prevent blindness
caused by Neisseria gonorrhoeae or Chlamydia trachomatis acquired during birth.
5. A nurse is teaching a postpartum client about mastitis. Which statement by the client
indicates a need for further teaching?
A. I should continue to breastfeed on both sides.
B. I will wear a supportive, non-underwire bra.
C. I need to take all my antibiotics as prescribed.
D. I will stop breastfeeding on the affected side until the infection clears.
Answer: D
Rationale: Emptying the breast is crucial in managing mastitis. Stopping breastfeeding on
the affected side can lead to an abscess or worsen the infection.
6. Which of the following is the most common cause of early postpartum hemorrhage (within
the first 24 hours)?
A. Retained placental fragments
B. Uterine atony
C. Lacerations of the birth canal
D. Disseminated intravascular coagulation (DIC)
Answer: B
1. A nurse is assessing a client who is 2 hours postpartum and observes that the fundus is
displaced to the right and above the umbilicus. What is the priority nursing action?
A. Massage the fundus immediately.
B. Administer oxytocin as ordered.
C. Assist the client to the bathroom to void.
D. Notify the provider of a potential hemorrhage.
Answer: C
Rationale: A fundus that is displaced to the right and above the umbilicus is a classic sign
of a full bladder, which can prevent the uterus from contracting effectively and lead to
hemorrhage.
2. Which of the following describes lochia serosa?
A. Pinkish-brown discharge lasting from day 4 to day 10 postpartum.
B. Bright red discharge lasting 1-3 days postpartum.
C. Yellow-white discharge lasting from day 11 to 6 weeks postpartum.
D. Bloody discharge containing small clots and decidua.
Answer: A
,Rationale: Lochia serosa is the second stage of postpartum discharge, appearing pinkish-
brown and typically lasting from the 4th to the 10th day after delivery.
3. A newborn is being assessed at 1 minute of life. The heart rate is 110, there is a weak cry,
some flexion of extremities, the body is pink with blue hands and feet, and the infant
grimaces when suctioned. What is the APGAR score?
A. 6
B. 8
C. 7
D. 9
Answer: C
Rationale: Heart rate > 100 (2), Weak cry (1), Some flexion (1), Acrocyanosis (1), Grimace
(2) = 7.
4. Which medication is standardly administered to newborns within 1 hour of birth to
prevent ophthalmia neonatorum?
A. Vitamin K (Phytonadione)
B. Hepatitis B vaccine
C. Triple dye
D. Erythromycin ophthalmic ointment
Answer: D
, Rationale: Erythromycin ointment is applied to the newborn’s eyes to prevent blindness
caused by Neisseria gonorrhoeae or Chlamydia trachomatis acquired during birth.
5. A nurse is teaching a postpartum client about mastitis. Which statement by the client
indicates a need for further teaching?
A. I should continue to breastfeed on both sides.
B. I will wear a supportive, non-underwire bra.
C. I need to take all my antibiotics as prescribed.
D. I will stop breastfeeding on the affected side until the infection clears.
Answer: D
Rationale: Emptying the breast is crucial in managing mastitis. Stopping breastfeeding on
the affected side can lead to an abscess or worsen the infection.
6. Which of the following is the most common cause of early postpartum hemorrhage (within
the first 24 hours)?
A. Retained placental fragments
B. Uterine atony
C. Lacerations of the birth canal
D. Disseminated intravascular coagulation (DIC)
Answer: B
