NRSG 3302 MATERNITY FINAL
COMPREHENSIVE EXAMINATION TEST WITH
COMPLETE QUESTIONS AND SOLUTIONS
◉ A nurse is caring for a client in the first hour following a vaginal
delivery. What is the priority nursing intervention?
A. Facilitate bonding between the mother and infant.
B. Assess the fundus for location, position, and tone.
C. Administer pain medications.
D. Inspect the perineum for tearing. Answer: A. (not wrong, but there
is a more right answer) Facilitate bonding between the mother and
infant.
Rationale: Facilitating bonding is the priority in the first hour
following delivery.
B. (Correct) Assess the fundus for location, position, and tone.
Rationale: The risk for postpartum hemorrhage is the greatest within
the first hour following delivery. The fundus should be assessed for
location, position, and tone every 15 minutes for the first hour.
C. Administer pain medications.
,Rationale: Pain medication may be ordered, but is not the priority of
the nurse at this time.
D: Inspect the perineum for tearing.
Rationale: Careful inspection of the perineum is the job of the
healthcare provider immediately following delivery.
◉ A nurse is caring for a client in the immediate postpartum period.
Upon assessment, the nurse notes heavy bleeding and a boggy uterus
that does not respond to fundal massage. What are the priority nursing
actions? Place in the correct order.
1. Increase the frequency of vital signs.
2. Notify the physician or midwife of excessive blood loss.
3. Perform fundal massage.
4. Titrate the standing order of oxytocin as appropriate. Answer: 1.
Perform fundal massage.
2. Titrate the standing order of oxytocin as appropriate.
3. Notify the physician or midwife of excessive blood loss.
4. Increase the frequency of vital signs.
Rationale: Immediate nursing actions for excessive bleeding include
massaging the uterus if it is boggy and following the standing order
for oxytocin administration, then notifying the healthcare provider.
, While awaiting the arrival of the evaluating clinician, the bedside
nurse should increase the frequency of vital signs.
◉ When educating a non-breastfeeding primiparous client, what
information is important for the nurse to include? Select all that apply.
1. "Wear a supportive bra or sports bra 24 hours a day."
2. "If your breasts become engorged, you should pump to relieve the
pressure."
3. "Do not apply ice packs to the breasts because it will stimulate milk
production."
4. "You can take an analgesic for pain."
5. "You may experience milk leakage for the first 1 to 2 weeks."
Answer: 1. (CORRECT) "Wear a supportive bra or sports bra 24
hours a day."
Rationale: Non-breastfeeding women should be instructed to wear a
supportive bra until their breasts become soft.
2. "If your breasts become engorged, you should pump to relieve the
pressure."
Rationale: Women should avoid expending milk or stimulating the
breasts.
COMPREHENSIVE EXAMINATION TEST WITH
COMPLETE QUESTIONS AND SOLUTIONS
◉ A nurse is caring for a client in the first hour following a vaginal
delivery. What is the priority nursing intervention?
A. Facilitate bonding between the mother and infant.
B. Assess the fundus for location, position, and tone.
C. Administer pain medications.
D. Inspect the perineum for tearing. Answer: A. (not wrong, but there
is a more right answer) Facilitate bonding between the mother and
infant.
Rationale: Facilitating bonding is the priority in the first hour
following delivery.
B. (Correct) Assess the fundus for location, position, and tone.
Rationale: The risk for postpartum hemorrhage is the greatest within
the first hour following delivery. The fundus should be assessed for
location, position, and tone every 15 minutes for the first hour.
C. Administer pain medications.
,Rationale: Pain medication may be ordered, but is not the priority of
the nurse at this time.
D: Inspect the perineum for tearing.
Rationale: Careful inspection of the perineum is the job of the
healthcare provider immediately following delivery.
◉ A nurse is caring for a client in the immediate postpartum period.
Upon assessment, the nurse notes heavy bleeding and a boggy uterus
that does not respond to fundal massage. What are the priority nursing
actions? Place in the correct order.
1. Increase the frequency of vital signs.
2. Notify the physician or midwife of excessive blood loss.
3. Perform fundal massage.
4. Titrate the standing order of oxytocin as appropriate. Answer: 1.
Perform fundal massage.
2. Titrate the standing order of oxytocin as appropriate.
3. Notify the physician or midwife of excessive blood loss.
4. Increase the frequency of vital signs.
Rationale: Immediate nursing actions for excessive bleeding include
massaging the uterus if it is boggy and following the standing order
for oxytocin administration, then notifying the healthcare provider.
, While awaiting the arrival of the evaluating clinician, the bedside
nurse should increase the frequency of vital signs.
◉ When educating a non-breastfeeding primiparous client, what
information is important for the nurse to include? Select all that apply.
1. "Wear a supportive bra or sports bra 24 hours a day."
2. "If your breasts become engorged, you should pump to relieve the
pressure."
3. "Do not apply ice packs to the breasts because it will stimulate milk
production."
4. "You can take an analgesic for pain."
5. "You may experience milk leakage for the first 1 to 2 weeks."
Answer: 1. (CORRECT) "Wear a supportive bra or sports bra 24
hours a day."
Rationale: Non-breastfeeding women should be instructed to wear a
supportive bra until their breasts become soft.
2. "If your breasts become engorged, you should pump to relieve the
pressure."
Rationale: Women should avoid expending milk or stimulating the
breasts.
