NUR 202 Exam 4 V2 | NUR 202 Maternal Newborn
Nursing | Actual Q&A with Rationale (NUR202
Exam 4) | Jersey College of Nursing
1. A nurse is reviewing the medical records of several postpartum clients. Which of the
following factors increase a client’s risk for postpartum hemorrhage? (Select All That Apply)
A. Large for gestational age (LGA) infant
B. Prolonged labor
C. Multiparity
D. Polyhydramnios
E. Primigravida status
F. Magnesium sulfate infusion during labor
Correct Answer: A, B, C, D, F
Explanation: Postpartum hemorrhage is frequently caused by uterine atony, which results
from overdistention of the uterus by factors like macrosomia or polyhydramnios.
Prolonged labor can exhaust the uterine muscle, while magnesium sulfate acts as a muscle
relaxant, further increasing the risk of atony. The nurse must closely monitor these high-
risk clients for excessive bleeding and maintain fundal tone.
,2. A nurse is performing an APGAR assessment on a newborn at 1 minute. The infant has a
heart rate of 110 bpm, a weak cry, some flexion of the extremities, grimacing, and a pink
body with blue extremities. What is the APGAR score?
A. 5
B. 7
C. 6
D. 8
Correct Answer: C
Explanation: The infant receives 2 points for heart rate over 100, 1 point for a weak cry, 1
point for flexion, 1 point for grimace, and 1 point for acrocyanosis. This totals 6 points,
indicating the newborn may require some resuscitation efforts or close observation.
APGAR scores are performed at 1 and 5 minutes to assess the newborn’s immediate
transition to extrauterine life.
3. A nurse is providing discharge teaching to a new mother regarding umbilical cord care.
Which instruction should the nurse include?
A. Apply petroleum jelly to the cord with every diaper change.
B. Submerge the infant in a tub bath to keep the area clean.
C. Clean the cord base with hydrogen peroxide twice daily.
D. Keep the diaper folded below the umbilical cord.
, Correct Answer: D
Explanation: Keeping the diaper folded below the cord prevents irritation and
contamination from urine or stool. The cord should be kept dry and exposed to air to
facilitate the drying and sloughing process. Parents should be instructed to only use sponge
baths until the cord stump has completely fallen off.
4. Which of the following mechanisms of heat loss is demonstrated when a newborn is placed
on a cold scale for weighing?
A. Conduction
B. Radiation
C. Evaporation
D. Convection
Correct Answer: A
Explanation: Conduction is the loss of body heat through direct contact with a cooler
surface. To prevent this, the nurse should place a warm blanket or paper on the scale
before weighing the infant. Maintaining a neutral thermal environment is critical to prevent
cold stress in the neonate.
5. A nurse is assessing a client 2 hours postpartum and finds the fundus is boggy and
displaced to the right of the midline. What is the priority nursing action?
A. Massage the fundus until firm.
B. Assist the client to the bathroom to void.
Nursing | Actual Q&A with Rationale (NUR202
Exam 4) | Jersey College of Nursing
1. A nurse is reviewing the medical records of several postpartum clients. Which of the
following factors increase a client’s risk for postpartum hemorrhage? (Select All That Apply)
A. Large for gestational age (LGA) infant
B. Prolonged labor
C. Multiparity
D. Polyhydramnios
E. Primigravida status
F. Magnesium sulfate infusion during labor
Correct Answer: A, B, C, D, F
Explanation: Postpartum hemorrhage is frequently caused by uterine atony, which results
from overdistention of the uterus by factors like macrosomia or polyhydramnios.
Prolonged labor can exhaust the uterine muscle, while magnesium sulfate acts as a muscle
relaxant, further increasing the risk of atony. The nurse must closely monitor these high-
risk clients for excessive bleeding and maintain fundal tone.
,2. A nurse is performing an APGAR assessment on a newborn at 1 minute. The infant has a
heart rate of 110 bpm, a weak cry, some flexion of the extremities, grimacing, and a pink
body with blue extremities. What is the APGAR score?
A. 5
B. 7
C. 6
D. 8
Correct Answer: C
Explanation: The infant receives 2 points for heart rate over 100, 1 point for a weak cry, 1
point for flexion, 1 point for grimace, and 1 point for acrocyanosis. This totals 6 points,
indicating the newborn may require some resuscitation efforts or close observation.
APGAR scores are performed at 1 and 5 minutes to assess the newborn’s immediate
transition to extrauterine life.
3. A nurse is providing discharge teaching to a new mother regarding umbilical cord care.
Which instruction should the nurse include?
A. Apply petroleum jelly to the cord with every diaper change.
B. Submerge the infant in a tub bath to keep the area clean.
C. Clean the cord base with hydrogen peroxide twice daily.
D. Keep the diaper folded below the umbilical cord.
, Correct Answer: D
Explanation: Keeping the diaper folded below the cord prevents irritation and
contamination from urine or stool. The cord should be kept dry and exposed to air to
facilitate the drying and sloughing process. Parents should be instructed to only use sponge
baths until the cord stump has completely fallen off.
4. Which of the following mechanisms of heat loss is demonstrated when a newborn is placed
on a cold scale for weighing?
A. Conduction
B. Radiation
C. Evaporation
D. Convection
Correct Answer: A
Explanation: Conduction is the loss of body heat through direct contact with a cooler
surface. To prevent this, the nurse should place a warm blanket or paper on the scale
before weighing the infant. Maintaining a neutral thermal environment is critical to prevent
cold stress in the neonate.
5. A nurse is assessing a client 2 hours postpartum and finds the fundus is boggy and
displaced to the right of the midline. What is the priority nursing action?
A. Massage the fundus until firm.
B. Assist the client to the bathroom to void.
