NUR 231 Exam 3 Actual Exam V2 | NUR 231 Childbearing & Child
Caring Family (NUR231 Exam 3) | Galen College of Nursing
1. A nurse is performing a postpartum assessment using the BUBBLE-HE acronym. Upon
palpating the fundus, the nurse finds it is boggy and displaced to the right of the midline.
What is the most appropriate initial nursing action?
A. Administer a PRN dose of oxytocin as ordered.
B. Perform vigorous fundal massage until the uterus is firm.
C. Encourage the client to void and then reassess the fundus.
D. Notify the provider of potential uterine atony.
Answer: C
Rationale: A displaced fundus to the right of the midline is a classic sign of a full bladder,
which can prevent the uterus from contracting effectively. Encouraging the patient to void
will allow the uterus to return to the midline and contract, reducing the risk of hemorrhage.
The nurse should always assess for bladder distension before escalating interventions for a
boggy, displaced fundus.
2. A nurse is caring for a client 4 hours post-delivery who is experiencing heavy vaginal
bleeding. Which assessment finding would most likely indicate that the bleeding is due to a
cervical laceration rather than uterine atony?
A. A soft, boggy fundus located above the umbilicus.
B. A firm fundus with a continuous trickle of bright red blood.
C. Presence of large clots in the vaginal vault.
D. The client reports severe perineal pain and pressure.
Answer: B
Rationale: Lacerations of the birth canal are suspected when bright red bleeding continues
despite a firm, contracted fundus. Uterine atony would typically present with a boggy
fundus, whereas lacerations often present as a steady stream or trickle. This distinction is
critical for determining whether the provider needs to perform a surgical repair or if fundal
massage is indicated.
3. The nurse is providing discharge teaching to a postpartum client. Which of the following
statements by the client indicates a need for further instruction regarding late postpartum
hemorrhage?
A. I should call my doctor if I pass clots larger than a lemon.
B. My lochia should gradually change from red to pink to white over several weeks.
,C. I will notify the clinic if my discharge has a foul odor.
D. It is normal for my bleeding to turn bright red again if I increase my activity.
Answer: D
Rationale: While increased activity can cause a slight increase in lochia, the return of
bright red bleeding after it has progressed to serosa or alba is a warning sign of late
postpartum hemorrhage or subinvolution. Clients must be taught that lochia should follow
a predictable progression of color and decrease in volume. Any reversal in this progression
requires immediate medical evaluation to rule out retained placental fragments.
4. A nurse is assessing a newborn 15 minutes after birth. The newborn has a heart rate of 110
bpm, a weak cry, some flexion of the extremities, grimacing when the feet are flicked, and a
pink body with blue hands and feet. What is the Apgar score?
A. 6
B. 5
C. 7
D. 8
Answer: A
Rationale: The score is calculated as follows: Heart rate >100 (2 points), Weak
cry/respiratory effort (1 point), Some flexion/muscle tone (1 point), Grimace/reflex
irritability (1 point), and Acrocyanosis (1 point). Totaling these results in an Apgar score of
6. A score of 4 to 6 indicates moderate distress and requires closer monitoring and
potential intervention.
5. Which mechanism of heat loss is a nurse preventing when they place a newborn on a pre-
warmed radiant warmer rather than a cold surface?
A. Conduction
B. Evaporation
C. Convection
D. Radiation
Answer: A
Rationale: Conduction is the loss of body heat to cooler surfaces in direct contact with the
newborn. By pre-warming the surface or using a warm blanket, the nurse minimizes the
temperature gradient between the infant and the surface. This is a vital nursing
intervention to prevent cold stress in the early neonatal period.
, 6. A nurse is teaching a mother about breastfeeding techniques. The nurse explains that to
ensure a proper latch, the infant’s mouth should cover which area?
A. The tip of the nipple only
B. The upper portion of the areola
C. The nipple and at least 1 inch of the areola
D. The side of the nipple where the infant’s tongue rests
Answer: C
Rationale: A proper latch involves the infant taking a large mouthful of breast tissue,
including the nipple and a significant portion of the areola. If the infant only latches onto
the nipple, it will result in ineffective milk transfer and cause maternal nipple pain or
trauma. The nurse should observe for the ‘flanged’ lip appearance and the absence of
clicking sounds during the feed.
7. A nurse notes a 12-hour-old newborn has a yellowish tint to the skin and sclera. Which
action should the nurse take first?
A. Document the finding as physiological jaundice.
B. Increase the frequency of breastfeeding to 10-12 times a day.
C. Check the newborn’s blood glucose level.
D. Notify the healthcare provider immediately.
Answer: D
Rationale: Jaundice appearing within the first 24 hours of life is considered pathologic
jaundice and requires immediate investigation. Pathologic jaundice often results from
hemolytic disease or other underlying conditions that can lead to dangerously high
bilirubin levels. Physiological jaundice, by contrast, typically appears after 24 hours of age.
8. The nurse is assessing a postpartum client for signs of a deep vein thrombosis (DVT). Which
finding should the nurse report to the provider?
A. Bilateral 1+ edema in the ankles.
B. Negative Homan’s sign with no pain.
C. Varicose veins that were present before pregnancy.
D. Unilateral calf warmth, redness, and tenderness.
Answer: D
Rationale: Unilateral symptoms such as localized warmth, redness, and swelling are classic
indicators of a DVT. While bilateral edema is common in the postpartum period due to fluid
Caring Family (NUR231 Exam 3) | Galen College of Nursing
1. A nurse is performing a postpartum assessment using the BUBBLE-HE acronym. Upon
palpating the fundus, the nurse finds it is boggy and displaced to the right of the midline.
What is the most appropriate initial nursing action?
A. Administer a PRN dose of oxytocin as ordered.
B. Perform vigorous fundal massage until the uterus is firm.
C. Encourage the client to void and then reassess the fundus.
D. Notify the provider of potential uterine atony.
Answer: C
Rationale: A displaced fundus to the right of the midline is a classic sign of a full bladder,
which can prevent the uterus from contracting effectively. Encouraging the patient to void
will allow the uterus to return to the midline and contract, reducing the risk of hemorrhage.
The nurse should always assess for bladder distension before escalating interventions for a
boggy, displaced fundus.
2. A nurse is caring for a client 4 hours post-delivery who is experiencing heavy vaginal
bleeding. Which assessment finding would most likely indicate that the bleeding is due to a
cervical laceration rather than uterine atony?
A. A soft, boggy fundus located above the umbilicus.
B. A firm fundus with a continuous trickle of bright red blood.
C. Presence of large clots in the vaginal vault.
D. The client reports severe perineal pain and pressure.
Answer: B
Rationale: Lacerations of the birth canal are suspected when bright red bleeding continues
despite a firm, contracted fundus. Uterine atony would typically present with a boggy
fundus, whereas lacerations often present as a steady stream or trickle. This distinction is
critical for determining whether the provider needs to perform a surgical repair or if fundal
massage is indicated.
3. The nurse is providing discharge teaching to a postpartum client. Which of the following
statements by the client indicates a need for further instruction regarding late postpartum
hemorrhage?
A. I should call my doctor if I pass clots larger than a lemon.
B. My lochia should gradually change from red to pink to white over several weeks.
,C. I will notify the clinic if my discharge has a foul odor.
D. It is normal for my bleeding to turn bright red again if I increase my activity.
Answer: D
Rationale: While increased activity can cause a slight increase in lochia, the return of
bright red bleeding after it has progressed to serosa or alba is a warning sign of late
postpartum hemorrhage or subinvolution. Clients must be taught that lochia should follow
a predictable progression of color and decrease in volume. Any reversal in this progression
requires immediate medical evaluation to rule out retained placental fragments.
4. A nurse is assessing a newborn 15 minutes after birth. The newborn has a heart rate of 110
bpm, a weak cry, some flexion of the extremities, grimacing when the feet are flicked, and a
pink body with blue hands and feet. What is the Apgar score?
A. 6
B. 5
C. 7
D. 8
Answer: A
Rationale: The score is calculated as follows: Heart rate >100 (2 points), Weak
cry/respiratory effort (1 point), Some flexion/muscle tone (1 point), Grimace/reflex
irritability (1 point), and Acrocyanosis (1 point). Totaling these results in an Apgar score of
6. A score of 4 to 6 indicates moderate distress and requires closer monitoring and
potential intervention.
5. Which mechanism of heat loss is a nurse preventing when they place a newborn on a pre-
warmed radiant warmer rather than a cold surface?
A. Conduction
B. Evaporation
C. Convection
D. Radiation
Answer: A
Rationale: Conduction is the loss of body heat to cooler surfaces in direct contact with the
newborn. By pre-warming the surface or using a warm blanket, the nurse minimizes the
temperature gradient between the infant and the surface. This is a vital nursing
intervention to prevent cold stress in the early neonatal period.
, 6. A nurse is teaching a mother about breastfeeding techniques. The nurse explains that to
ensure a proper latch, the infant’s mouth should cover which area?
A. The tip of the nipple only
B. The upper portion of the areola
C. The nipple and at least 1 inch of the areola
D. The side of the nipple where the infant’s tongue rests
Answer: C
Rationale: A proper latch involves the infant taking a large mouthful of breast tissue,
including the nipple and a significant portion of the areola. If the infant only latches onto
the nipple, it will result in ineffective milk transfer and cause maternal nipple pain or
trauma. The nurse should observe for the ‘flanged’ lip appearance and the absence of
clicking sounds during the feed.
7. A nurse notes a 12-hour-old newborn has a yellowish tint to the skin and sclera. Which
action should the nurse take first?
A. Document the finding as physiological jaundice.
B. Increase the frequency of breastfeeding to 10-12 times a day.
C. Check the newborn’s blood glucose level.
D. Notify the healthcare provider immediately.
Answer: D
Rationale: Jaundice appearing within the first 24 hours of life is considered pathologic
jaundice and requires immediate investigation. Pathologic jaundice often results from
hemolytic disease or other underlying conditions that can lead to dangerously high
bilirubin levels. Physiological jaundice, by contrast, typically appears after 24 hours of age.
8. The nurse is assessing a postpartum client for signs of a deep vein thrombosis (DVT). Which
finding should the nurse report to the provider?
A. Bilateral 1+ edema in the ankles.
B. Negative Homan’s sign with no pain.
C. Varicose veins that were present before pregnancy.
D. Unilateral calf warmth, redness, and tenderness.
Answer: D
Rationale: Unilateral symptoms such as localized warmth, redness, and swelling are classic
indicators of a DVT. While bilateral edema is common in the postpartum period due to fluid
