4. A nurse is preparing to perform a fundal assessment on a postpartum client.

The
initial nursing action in performing this assessment is which of the following?

A. Ask the client to turn on her side

B. Ask the client to lie flat on her back with the knees and legs flat and straight.
C. Ask the mother to urinate and empty her bladder
D. Massage the fundus gently before determining the level of the fundus.
8. A PP nurse is providing instructions to a woman after delivery of a healthy
newborn infant. The nurse instructs the mother that she should expect normal bowel
elimination to return:

A. One the day of the delivery

B. 3 days PP
C. 7 days PP
D. within 2 weeks PP
10. A nurse is caring for a PP woman who has received epidural anesthesia and is
monitoring the woman for the presence of a vulva hematoma. Which of the following
assessment findings would best indicate the presence of a hematoma?

A. Complaints of a tearing sensation

B. Complaints of intense pain
C. Changes in vital signs
D. Signs of heavy bruising
13. A nurse is monitoring a new mother in the PP period for signs of hemorrhage.
Which of the following signs, if noted in the mother, would be an early sign of
excessive blood loss?

A. A temperature of 100.4*F
B. An increase in the pulse from 88 to 102 BPM
C. An increase in the respiratory rate from 18 to 22 breaths per minute
D. A blood pressure change from 130/88 to 124/80 mm Hg
14. A nurse is preparing to assess the uterine fundus of a client in the immediate
postpartum period. When the nurse locates the fundus, she notes that the uterus feels
soft and boggy. Which of the following nursing interventions would be most
appropriate initially?

A. Massage the fundus until it is firm

B. Elevate the mothers legs
C. Push on the uterus to assist in expressing clots
D. Encourage the mother to void
15. A PP nurse is assessing a mother who delivered a healthy newborn infant by C-
section. The nurse is assessing for signs and symptoms of superficial venous
thrombosis. Which of the following signs or symptoms would the nurse note if
superficial venous thrombosis were present?

A. Paleness of the calf area

B. Enlarged, hardened veins
C. Coolness of the calf area
D. Palpable dorsalis pedis pulses
18. A nurse performs an assessment on a client who is 4 hours PP. The nurse notes
that the client has cool, clammy skin and is restless and excessively thirsty. The nurse
prepares immediately to:

A. Assess for hypovolemia and notify the health care provider

B. Begin hourly pad counts and reassure the client
C. Begin fundal massage and start oxygen by mask
D. Elevate the head of the bed and assess vital signs
22. Methergine or pitocin is prescribed for a woman to treat PP hemorrhage. Before
administration of these medications, the priority nursing assessment is to check the:

A. Amount of lochia
B. Blood pressure
C. Deep tendon reflexes
D. Uterine tone
23. Methergine or pitocin are prescribed for a client with PP hemorrhage. Before
administering the medication(s), the nurse contacts the health provider who prescribed
the medication(s) in which of the following conditions is documented in the client’s
medical history?

A. Peripheral vascular disease

B. Hypothyroidism
C. Hypotension
D. Type 1 diabetes
24. Which of the following factors might result in a decreased supply of breastmilk in
a PP mother?

A. Supplemental feedings with formula

B. Maternal diet high in vitamin C
C. An alcoholic drink
D. Frequent feedings
25. Which of the following interventions would be helpful to a breastfeeding mother
who is experiencing engorged breasts?

A. Applying ice
B. Applying a breast binder
C. Teaching how to express her breasts in a warm shower
D. Administering bromocriptine (Parlodel)
26. On completing a fundal assessment, the nurse notes the fundus is situated on the
client’s left abdomen. Which of the following actions is appropriate?

A. Ask the client to empty her bladder

B. Straight catheterize the client immediately
C. Call the client’s health provider for direction
D. Straight catheterize the client for half of her uterine volume
28. Which of the following findings would be expected when assessing the
postpartum client?

A. Fundus 1 cm above the umbilicus 1 hour postpartum

B. Fundus 1 cm above the umbilicus on postpartum day 3
C. Fundus palpable in the abdomen at 2 weeks postpartum
D. Fundus slightly to the right; 2 cm above umbilicus on postpartum day 2
30. On which of the postpartum days can the client expect lochia serosa?

A. Days 3 and 4 PP
B. Days 3 to 10 PP
C. Days 10-14 PP
D. Days 14 to 42 PP
31. Which of the following behaviors characterizes the PP mother in the taking
inphase?

A. Passive and dependant

B. Striving for independence and autonomy
C. Curious and interested in care of the baby
D. Exhibiting maximum readiness for new learning
33. What type of milk is present in the breasts 7 to 10 days PP?

A. Colostrum
B. Hind milk
C. Mature milk
D. Transitional milk
38. On the first PP night, a client requests that her baby be sent back to the nursery so
she can get some sleep. The client is most likely in which of the following phases?

A. Depression phase
B. Letting-go phase
C. Taking-hold phase
D. Taking-in phase
39. Which of the following physiological responses is considered normal in the early
postpartum period?

A. Urinary urgency and dysuria

B. Rapid diuresis
C. Decrease in blood pressure
D. Increase motility of the GI system
40. During the 3rd PP day, which of the following observations about the client would
the nurse be most likely to make?

A. The client appears interested in learning about neonatal care

B. The client talks a lot about her birth experience
C. The client sleeps whenever the neonate isn’t present
D. The client requests help in choosing a name for the neonate.
49. Perineal care is an important infection control measure. When evaluating a
postpartum woman’s perineal care technique, the nurse would recognize the need for
further instruction if the woman:

A. Uses soap and warm water to wash the vulva and perineum
B. Washes from symphysis pubis back to episiotomy
C. Changes her perineal pad every 2 – 3 hours
D. Uses the peribottle to rinse upward into her vagina
50. Which measure would be least effective in preventing postpartum hemorrhage?

A. Administer Methergine 0.2 mg every 6 hours for 4 doses as ordered

B. Encourage the woman to void every 2 hours
C. Massage the fundus every hour for the first 24 hours following birth
D. Teach the woman the importance of rest and nutrition to enhance healing
51. When making a visit to the home of a postpartum woman one week after birth, the
nurse should recognize that the woman would characteristically:

A. Express a strong need to review events and her behavior during the process of
labor and birth
B. Exhibit a reduced attention span, limiting readiness to learn
 C. Vacillate between the desire to have her own nurturing needs met and the
need to take charge of her own care and that of her newborn
D. Have reestablished her role as a spouse/partner
53. Parents can facilitate the adjustment of their other children to a new baby by:

A. Having the children choose or make a gift to give to the new baby upon its
arrival home
B. Emphasizing activities that keep the new baby and other children together
C. Having the mother carry the new baby into the home so she can show the other
children the new baby
D. Reducing stress on other children by limiting their involvement in the care of the
new baby
55. All of the following are important in the immediate care of the premature
neonate. Which nursing activity should have the greatest priority?

A. Instillation of antibiotic in the eyes

B. Identification by bracelet and foot prints
C. Placement in a warm environment
D. Neurological assessment to determine gestational age

4. Answer: C. Ask the mother to urinate and empty her bladder. Before starting the
fundal assessment, the nurse should ask the mother to empty her bladder so that an
accurate assessment can be done. When the nurse is performing fundal assessment,
the nurse asks the woman to lie flat on her back with the knees flexed. Massaging
the fundus is not appropriate unless the fundus is boggy and soft, and then it
should be massaged gently until firm.

8. Answer: B. 3 days PP. After birth, the nurse should auscultate the woman’s abdomen in all four
quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3
days PP. Surgery, anesthesia, and the use of narcotics and pain control agents also contribute to the
longer period of altered bowel function.

10. Answer: C. Changes in vital signs. Because the woman has had epidural anesthesia and is
anesthetized, she cannot feel pain, pressure, or a tearing sensation. Changes in vitals indicate
hypovolemia in the anesthetized PP woman with vulvar hematoma. Heavy bruising may be visualized,
but vital sign changes indicate hematoma caused by blood collection in the perineal tissues.

13. Answer: B. An increase in the pulse from 88 to 102 BPM. During the 4th stage of labor, the
maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first
hour. A rising pulse is an early sign of excessive blood loss because the heart pumps faster to
compensate for reduced blood volume. The blood pressure will fall as the blood volume diminishes, but
a decreased blood pressure would not be the earliest sign of hemorrhage. A slight rise in temperature is
normal. The respiratory rate is increased slightly.

14. Answer: A. Massage the fundus until it is firm. If the uterus is not contracted firmly, the first
intervention is to massage the fundus until it is firm and to express clots that may have accumulated in
the uterus. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage.
Elevating the client’s legs and encouraging the client to void will not assist in managing uterine atony. If
the uterus does not remain contracted as a result of the uterine massage, the problem may be
distended bladder and the nurse should assist the mother to urinate, but this would not be the initial
action.

15. Answer: B. Enlarged, hardened veins. Thrombosis of the superficial veins is usually accompanied
by signs and symptoms of inflammation. These include swelling of the involved extremity and redness,
tenderness, and warmth.

18. Answer: A. Assess for hypovolemia and notify the health care provider. Symptoms of
hypovolemia include cool, clammy, pale skin, sensations of anxiety or impending doom, restlessness,
and thirst. When these symptoms are present, the nurse should further assess for hypovolemia and
notify the health care provider.

22. Answer: B. Blood pressure. Methergine and pitocin are agents that are used to prevent or
control postpartum hemorrhage by contracting the uterus. They cause continuous uterine contractions
and may elevate blood pressure. A priority nursing intervention is to check blood pressure. The
physician should be notified if hypertension is present.

23. Answer: A. Peripheral vascular disease. These medications are avoided in clients with significant
cardiovascular disease, peripheral disease, hypertension, eclampsia, or preeclampsia. These conditions
are worsened by the vasoconstriction effects of these medications.

24. Answer: A. Supplemental feedings with formula. Routine formula supplementation may
interfere with establishing an adequate milk volume because decreased stimulation to the mother’s
nipples affects hormonal levels and milk production.

25. Answer: C. Teaching how to express her breasts in a warm shower. Teaching the client how to
express her breasts in a warm shower aids with let-down and will give temporary relief. Ice can promote
comfort by vasoconstriction, numbing, and discouraging further letdown of milk.

26. Answer: A. Ask the client to empty her bladder. A full bladder may displace the uterine fundus to
the left or right side of the abdomen. Catheterization is unnecessary invasive if the woman can void on
her own.

28. Answer: A. Fundus 1 cm above the umbilicus 1 hour postpartum. Within the first 12 hours
postpartum, the fundus usually is approximately 1 cm above the umbilicus. The fundus should be below
the umbilicus by PP day 3. The fundus shouldn’t be palpated in the abdomen after day 10.
30. Answer: B. Days 3 to 10 PP. On the third and fourth PP days, the lochia becomes a pale pink or
brown and contains old blood, serum, leukocytes, and tissue debris. This type of lochia usually lasts until
PP day 10. Lochia rubra usually last for the first 3 to 4 days PP. Lochia alba, which contain leukocytes,
decidua, epithelial cells, mucus, and bacteria, may continue for 2 to 6 weeks PP.

31. Answer: A. Passive and dependant. During the taking in phase, which usually lasts 1-3 days, the
mother is passive and dependent and expresses her own needs rather than the neonate’s needs. The
taking hold phase usually lasts from days 3-10 PP. During this stage, the mother strives for
independence and autonomy; she also becomes curious and interested in the care of the baby and is
most ready to learn.

33. Answer: D. Transitional milk. Transitional milk comes after colostrum and usually lasts until 2
weeks PP.

38. Answer: D. Taking-in phase. The taking-in phase occurs in the first 24 hours after birth. The
mother is concerned with her own needs and requires support from staff and relatives. The taking-hold
phase occurs when the mother is ready to take responsibility for her care as well as the infants care. The
letting-go phase begins several weeks later, when the mother incorporates the new infant into the
family unit.

39. Answer: B. Rapid diuresis. In the early PP period, there’s an increase in the glomerular filtration
rate and a drop in the progesterone levels, which result in rapid diuresis. There should be no urinary
urgency, though a woman may feel anxious about voiding. There’s a minimal change in blood pressure
following childbirth, and a residual decrease in GI motility.

40. Answer: A. The client appears interested in learning about neonatal care. The third to tenth days
of PP care are the “taking-hold” phase, in which the new mother strives for independence and is eager
for her neonate. The other options describe the phase in which the mother relives her birth experience.

49. Answer: D. Uses the peribottle to rinse upward into her vagina. Responses A, B, and C are all
appropriate measures. The peribottle should be used in a backward direction over the perineum. The
flow should never be directed upward into the vagina since debris would be forced upward into the
uterus through the still-open cervix.

50. Answer: C. Massage the fundus every hour for the first 24 hours following birth. The fundus
should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax.
Responses A, B, and D are all effective measures to enhance and maintain contraction of the uterus and
to facilitate healing.

51. Answer: C. Vacillate between the desire to have her own nurturing needs met and the need to
take charge of her own care and that of her newborn. One week after birth the woman should exhibit
behaviors characteristic of the taking-hold stage as described in response C. This stage lasts for as long
as 4 to 5 weeks after birth. Responses A and B are characteristic of the taking-in stage, which lasts for
the first few days after birth. Response D reflects the letting-go stage, which indicates that psychosocial
recovery is complete.

53. Answer: A. Having the children choose or make a gift to give to the new baby upon its arrival
home. Special time should be set aside just for the other children without interruption from the
newborn. Someone other than the mother should carry the baby into the home so she can give full
attention to greeting her other children. Children should be actively involved in the care of the baby
according to their ability without overwhelming them.

55. Answer: C. Placement in a warm environment