NUR 231 Exam 3 Actual Exam V1 | NUR 231 Childbearing & Child
Caring Family (NUR231 Exam 3) | Galen College of Nursing
1. A nurse is assessing a client 2 hours postpartum and finds the fundus to be boggy and
displaced to the right. What is the priority nursing intervention?
A. Encourage the client to void or catheterize if necessary
B. Administer oxytocin as prescribed
C. Perform vigorous fundal massage
D. Notify the healthcare provider immediately
Answer: A
Rationale: This examination assesses critical competencies in maternal-newborn nursing,
focusing on the physiological and psychological transitions occurring during the
postpartum period. It evaluates the student’s ability to identify complications such as
hemorrhage and infection while promoting family-centered care and breastfeeding success.
A displaced fundus is most often caused by a full bladder, which prevents effective uterine
contraction.
2. The nurse is evaluating an infant at 1 minute of life. The infant has a heart rate of 110, a
weak cry, some flexion of extremities, grimace when stimulated, and a pink body with blue
extremities. What is the APGAR score?
A. 6
B. 5
C. 7
D. 8
Answer: A
Rationale: The score is calculated as: Heart rate >100 (2), weak cry (1), some flexion (1),
grimace (1), and acrocyanosis (1), totaling 6.
3. Which mechanism of heat loss is a nurse preventing when drying a newborn immediately
after birth?
A. Conduction
B. Radiation
C. Convection
D. Evaporation
, Answer: D
Rationale: Evaporation occurs when moisture on the skin is converted to vapor; drying the
infant removes the moisture and prevents this heat loss.
4. A client who is 2 days postpartum expresses a desire to talk about her labor and birth
experience. The nurse recognizes this as which phase of maternal adaptation?
A. Taking-hold phase
B. Taking-in phase
C. Letting-go phase
D. Attachment phase
Answer: B
Rationale: The Taking-in phase is characterized by the mother’s need to review her birth
experience and her focus on her own basic needs like food and sleep.
5. Which assessment finding in a postpartum client would most strongly suggest the
development of endometritis?
A. Lochia rubra on day 2
B. Temperature of 100.2 F (37.9 C)
C. Foul-smelling lochia and uterine tenderness
D. Breast engorgement and tenderness
Answer: C
Rationale: Foul-smelling lochia and uterine tenderness are classic signs of a uterine
infection (endometritis).
6. The nurse is teaching a mother about breastfeeding. Which finding indicates that the infant
has a proper latch?
A. The infant’s lips are flanged outward and the chin touches the breast
B. The mother feels a pinching sensation on the nipple
C. The infant’s nose is pressed firmly against the breast
D. Only the tip of the nipple is in the infant’s mouth
Answer: A
Rationale: A proper latch involves the infant taking a large portion of the areola, with lips
flanged out and the chin touching the breast to ensure effective milk transfer and prevent
nipple trauma.
Caring Family (NUR231 Exam 3) | Galen College of Nursing
1. A nurse is assessing a client 2 hours postpartum and finds the fundus to be boggy and
displaced to the right. What is the priority nursing intervention?
A. Encourage the client to void or catheterize if necessary
B. Administer oxytocin as prescribed
C. Perform vigorous fundal massage
D. Notify the healthcare provider immediately
Answer: A
Rationale: This examination assesses critical competencies in maternal-newborn nursing,
focusing on the physiological and psychological transitions occurring during the
postpartum period. It evaluates the student’s ability to identify complications such as
hemorrhage and infection while promoting family-centered care and breastfeeding success.
A displaced fundus is most often caused by a full bladder, which prevents effective uterine
contraction.
2. The nurse is evaluating an infant at 1 minute of life. The infant has a heart rate of 110, a
weak cry, some flexion of extremities, grimace when stimulated, and a pink body with blue
extremities. What is the APGAR score?
A. 6
B. 5
C. 7
D. 8
Answer: A
Rationale: The score is calculated as: Heart rate >100 (2), weak cry (1), some flexion (1),
grimace (1), and acrocyanosis (1), totaling 6.
3. Which mechanism of heat loss is a nurse preventing when drying a newborn immediately
after birth?
A. Conduction
B. Radiation
C. Convection
D. Evaporation
, Answer: D
Rationale: Evaporation occurs when moisture on the skin is converted to vapor; drying the
infant removes the moisture and prevents this heat loss.
4. A client who is 2 days postpartum expresses a desire to talk about her labor and birth
experience. The nurse recognizes this as which phase of maternal adaptation?
A. Taking-hold phase
B. Taking-in phase
C. Letting-go phase
D. Attachment phase
Answer: B
Rationale: The Taking-in phase is characterized by the mother’s need to review her birth
experience and her focus on her own basic needs like food and sleep.
5. Which assessment finding in a postpartum client would most strongly suggest the
development of endometritis?
A. Lochia rubra on day 2
B. Temperature of 100.2 F (37.9 C)
C. Foul-smelling lochia and uterine tenderness
D. Breast engorgement and tenderness
Answer: C
Rationale: Foul-smelling lochia and uterine tenderness are classic signs of a uterine
infection (endometritis).
6. The nurse is teaching a mother about breastfeeding. Which finding indicates that the infant
has a proper latch?
A. The infant’s lips are flanged outward and the chin touches the breast
B. The mother feels a pinching sensation on the nipple
C. The infant’s nose is pressed firmly against the breast
D. Only the tip of the nipple is in the infant’s mouth
Answer: A
Rationale: A proper latch involves the infant taking a large portion of the areola, with lips
flanged out and the chin touching the breast to ensure effective milk transfer and prevent
nipple trauma.
