NUR 254 MATERNAL EXAM 2 QUESTIONS AND
CORRECT ANSWERS (VERIFIED ANSWERS) PLUS
RATIONALES 2026 Q&A | INSTANT DOWNLOAD PDF
Core Domains:
Postpartum Assessment and BUBBLE HE Framework
Newborn Adaptation to Extrauterine Life
Postpartum Hemorrhage: Early and Late
Postpartum Infections (Endometritis, Mastitis)
Newborn Assessment and Reflexes
Hyperbilirubinemia and Phototherapy
Rh Incompatibility and RhoGAM
Breastfeeding and Newborn Nutrition
Parent-Infant Attachment (Reciprocity, Synchrony)
Postpartum Psychosocial Complications
This comprehensive examination is designed to evaluate nursing knowledge essential for safe
and effective maternal-newborn care in the postpartum period. The examination covers key
concepts from Galen College of Nursing's NUR 254 Maternal-Newborn Nursing course,
including comprehensive postpartum maternal assessment, newborn transition and adaptation,
identification and management of postpartum complications, and evidence-based nursing
interventions. Questions emphasize clinical reasoning, prioritization, and the application of
nursing knowledge to real-world scenarios. Each item includes a verified correct answer
accompanied by a detailed rationale to reinforce learning and support exam preparation for the
2026 academic year.
SECTION ONE: QUESTIONS 1 – 50
Question 1
The nurse is caring for a postpartum client who delivered 24 hours ago. The client has a
temperature of 101.0°F. Which action should the nurse take FIRST?
A. Assess the client's breasts for redness and swelling
B. Determine if the client's lochia has a foul smell
C. Ask the client if she is experiencing calf pain
D. Instruct the client to drink 2-3 glasses of water within the next 24 hours
B. Determine if the client's lochia has a foul smell
, RATIONALE: A fever after 24 hours postpartum can indicate endometritis, an infection of
the uterine lining. Foul-smelling lochia is a classic sign of infection that warrants thorough
assessment. Early detection and intervention are critical to prevent sepsis and other
complications .
Question 2
The nurse notes that a postpartum client's fundus is boggy (soft) and displaced to the right, above
the umbilicus. What is the nurse's FIRST action?
A. Administer methylergonovine (Methergine)
B. Perform fundal massage and assist the client to void
C. Apply ice packs to the abdomen
D. Check the client's blood pressure
B. Perform fundal massage and assist the client to void
RATIONALE: A boggy, displaced fundus typically indicates a full bladder pushing the
uterus up and out of the midline. The first action is to massage the fundus to stimulate
contraction and assist the client to empty her bladder. This will allow the uterus to contract
effectively. Oxytocics are given only if massage and voiding do not resolve the issue .
Question 3
The nurse is caring for a postpartum client and observes heavy lochia rubra, saturating a perineal
pad in 15 minutes. What is the nurse's priority action?
A. Assess maternal blood pressure and pulse for signs of hypovolemic shock
B. Administer prescribed oxytocin
C. Palpate the bladder and have the client void if full
D. Call the healthcare provider
A. Assess maternal blood pressure and pulse for signs and symptoms of hypovolemic shock
RATIONALE: Saturation of a perineal pad in less than 15 minutes (or >500 mL blood loss
in the first 24 hours) indicates postpartum hemorrhage. The priority is to assess the client's
hemodynamic status (blood pressure, pulse) to detect early signs of hypovolemic shock. While
fundal massage and oxytocin are important interventions, assessment is the first step to
determine the severity of the client's condition .
Question 4
,The nurse is caring for a client who delivered a newborn by normal spontaneous vaginal delivery
24 hours ago. The client reports a full bladder. What is the nurse's best response?
A. "Please wait until your next scheduled assessment to void."
B. "Let me assist you to the bathroom to empty your bladder."
C. "You should drink less fluid so your bladder doesn't fill so quickly."
D. "I will insert a Foley catheter to empty your bladder."
B. "Let me assist you to the bathroom to empty your bladder."
RATIONALE: A full bladder can displace the uterus, contributing to increased bleeding and
preventing the uterus from contracting effectively. Encouraging voiding to relieve bladder
distention is a primary non-invasive intervention before escalating care. The nurse should assist
the client to the bathroom to maintain safety and prevent falls .
Question 5
Which postpartum infection is caused by STIs and chorioamnionitis?
A. Mastitis
B. Pneumonia
C. Cesarean wound infection
D. Postpartum endometritis
D. Postpartum endometritis
RATIONALE: Postpartum endometritis is an infection of the uterine decidua. It can be
caused by sexually transmitted infections or chorioamnionitis. Risk factors include prolonged
labor, cesarean birth, and internal fetal monitoring. Signs include fever, tachycardia, and foul-
smelling lochia .
Question 6
What is the most common reason for cracked, sore nipples in a breastfeeding mother?
A. Hungry infant
B. Pumping
C. Ineffective latch
D. Lack of supportive bra
C. Ineffective latch
RATIONALE: The most common cause of cracked, sore nipples is an ineffective latch.
When the baby does not take in enough of the areola, the nipple is compressed against the hard
, palate, causing trauma. Correct latch technique and position changes are the most important
interventions .
Question 7
Which of the following is a contraindication to the use of methylergonovine (Methergine) in a
postpartum client?
A. Uterine atony
B. Hypertension
C. Postpartum hemorrhage
D. Breastfeeding
B. Hypertension
RATIONALE: Methylergonovine causes vasoconstriction and is contraindicated in clients
with hypertension due to the risk of precipitating a hypertensive crisis. It is used to treat uterine
atony and postpartum hemorrhage. Other contraindications include preeclampsia and
cardiovascular disease .
Question 8
The nurse is caring for a postpartum client of Vietnamese descent. The client's husband brings a
large container of seaweed soup to the hospital. When the nurse enters the room, the husband
asks for help with warming the soup for the client. Which response is appropriate?
A. "I'll warm the soup in the microwave for you."
B. "What ingredients are in the soup?"
C. "Didn't you like your lunch today?"
D. "Is the doctor okay with you eating this soup?"
A. "I'll warm the soup in the microwave for you."
RATIONALE: Providing culturally sensitive support by assisting with warming traditional
food promotes comfort and respect for the client's cultural practices. In Vietnamese culture,
seaweed soup is traditionally consumed postpartum to support recovery and lactation. Supporting
cultural practices helps build trust and promotes nutritional intake .
Question 9
The nurse is caring for a breastfeeding, 4-day postpartum client. The client reports her breasts
feel heavy and painful. What should the nurse instruct the client to do before nursing the baby?
CORRECT ANSWERS (VERIFIED ANSWERS) PLUS
RATIONALES 2026 Q&A | INSTANT DOWNLOAD PDF
Core Domains:
Postpartum Assessment and BUBBLE HE Framework
Newborn Adaptation to Extrauterine Life
Postpartum Hemorrhage: Early and Late
Postpartum Infections (Endometritis, Mastitis)
Newborn Assessment and Reflexes
Hyperbilirubinemia and Phototherapy
Rh Incompatibility and RhoGAM
Breastfeeding and Newborn Nutrition
Parent-Infant Attachment (Reciprocity, Synchrony)
Postpartum Psychosocial Complications
This comprehensive examination is designed to evaluate nursing knowledge essential for safe
and effective maternal-newborn care in the postpartum period. The examination covers key
concepts from Galen College of Nursing's NUR 254 Maternal-Newborn Nursing course,
including comprehensive postpartum maternal assessment, newborn transition and adaptation,
identification and management of postpartum complications, and evidence-based nursing
interventions. Questions emphasize clinical reasoning, prioritization, and the application of
nursing knowledge to real-world scenarios. Each item includes a verified correct answer
accompanied by a detailed rationale to reinforce learning and support exam preparation for the
2026 academic year.
SECTION ONE: QUESTIONS 1 – 50
Question 1
The nurse is caring for a postpartum client who delivered 24 hours ago. The client has a
temperature of 101.0°F. Which action should the nurse take FIRST?
A. Assess the client's breasts for redness and swelling
B. Determine if the client's lochia has a foul smell
C. Ask the client if she is experiencing calf pain
D. Instruct the client to drink 2-3 glasses of water within the next 24 hours
B. Determine if the client's lochia has a foul smell
, RATIONALE: A fever after 24 hours postpartum can indicate endometritis, an infection of
the uterine lining. Foul-smelling lochia is a classic sign of infection that warrants thorough
assessment. Early detection and intervention are critical to prevent sepsis and other
complications .
Question 2
The nurse notes that a postpartum client's fundus is boggy (soft) and displaced to the right, above
the umbilicus. What is the nurse's FIRST action?
A. Administer methylergonovine (Methergine)
B. Perform fundal massage and assist the client to void
C. Apply ice packs to the abdomen
D. Check the client's blood pressure
B. Perform fundal massage and assist the client to void
RATIONALE: A boggy, displaced fundus typically indicates a full bladder pushing the
uterus up and out of the midline. The first action is to massage the fundus to stimulate
contraction and assist the client to empty her bladder. This will allow the uterus to contract
effectively. Oxytocics are given only if massage and voiding do not resolve the issue .
Question 3
The nurse is caring for a postpartum client and observes heavy lochia rubra, saturating a perineal
pad in 15 minutes. What is the nurse's priority action?
A. Assess maternal blood pressure and pulse for signs of hypovolemic shock
B. Administer prescribed oxytocin
C. Palpate the bladder and have the client void if full
D. Call the healthcare provider
A. Assess maternal blood pressure and pulse for signs and symptoms of hypovolemic shock
RATIONALE: Saturation of a perineal pad in less than 15 minutes (or >500 mL blood loss
in the first 24 hours) indicates postpartum hemorrhage. The priority is to assess the client's
hemodynamic status (blood pressure, pulse) to detect early signs of hypovolemic shock. While
fundal massage and oxytocin are important interventions, assessment is the first step to
determine the severity of the client's condition .
Question 4
,The nurse is caring for a client who delivered a newborn by normal spontaneous vaginal delivery
24 hours ago. The client reports a full bladder. What is the nurse's best response?
A. "Please wait until your next scheduled assessment to void."
B. "Let me assist you to the bathroom to empty your bladder."
C. "You should drink less fluid so your bladder doesn't fill so quickly."
D. "I will insert a Foley catheter to empty your bladder."
B. "Let me assist you to the bathroom to empty your bladder."
RATIONALE: A full bladder can displace the uterus, contributing to increased bleeding and
preventing the uterus from contracting effectively. Encouraging voiding to relieve bladder
distention is a primary non-invasive intervention before escalating care. The nurse should assist
the client to the bathroom to maintain safety and prevent falls .
Question 5
Which postpartum infection is caused by STIs and chorioamnionitis?
A. Mastitis
B. Pneumonia
C. Cesarean wound infection
D. Postpartum endometritis
D. Postpartum endometritis
RATIONALE: Postpartum endometritis is an infection of the uterine decidua. It can be
caused by sexually transmitted infections or chorioamnionitis. Risk factors include prolonged
labor, cesarean birth, and internal fetal monitoring. Signs include fever, tachycardia, and foul-
smelling lochia .
Question 6
What is the most common reason for cracked, sore nipples in a breastfeeding mother?
A. Hungry infant
B. Pumping
C. Ineffective latch
D. Lack of supportive bra
C. Ineffective latch
RATIONALE: The most common cause of cracked, sore nipples is an ineffective latch.
When the baby does not take in enough of the areola, the nipple is compressed against the hard
, palate, causing trauma. Correct latch technique and position changes are the most important
interventions .
Question 7
Which of the following is a contraindication to the use of methylergonovine (Methergine) in a
postpartum client?
A. Uterine atony
B. Hypertension
C. Postpartum hemorrhage
D. Breastfeeding
B. Hypertension
RATIONALE: Methylergonovine causes vasoconstriction and is contraindicated in clients
with hypertension due to the risk of precipitating a hypertensive crisis. It is used to treat uterine
atony and postpartum hemorrhage. Other contraindications include preeclampsia and
cardiovascular disease .
Question 8
The nurse is caring for a postpartum client of Vietnamese descent. The client's husband brings a
large container of seaweed soup to the hospital. When the nurse enters the room, the husband
asks for help with warming the soup for the client. Which response is appropriate?
A. "I'll warm the soup in the microwave for you."
B. "What ingredients are in the soup?"
C. "Didn't you like your lunch today?"
D. "Is the doctor okay with you eating this soup?"
A. "I'll warm the soup in the microwave for you."
RATIONALE: Providing culturally sensitive support by assisting with warming traditional
food promotes comfort and respect for the client's cultural practices. In Vietnamese culture,
seaweed soup is traditionally consumed postpartum to support recovery and lactation. Supporting
cultural practices helps build trust and promotes nutritional intake .
Question 9
The nurse is caring for a breastfeeding, 4-day postpartum client. The client reports her breasts
feel heavy and painful. What should the nurse instruct the client to do before nursing the baby?
