1.

A postpartum nurse is preparing to care for a woman who has just

delivered a healthy newborn infant. In the immediate postpartum period,
the nurse plans to take the woman’s vital signs:
A. Every 30 minutes during the first hour and then every hour for the next
two hours.
B. Every 15 minutes during the first hour and then every 30 minutes for the
next two hours.
C. Every hour for the first 2 hours and then every 4 hours.
D. Every 5 minutes for the first 30 minutes and then every hour for the next
4 hours.

Correct Answer: B. Every 15 minutes during the first hour and then every 30
minutes for the next two hours.
The initial or acute period involves the first 6–12 hours postpartum. This is a time
of rapid change with a potential for immediate crises such as postpartum
hemorrhage, uterine inversion, amniotic fluid embolism, and eclampsia.

2. A postpartum nurse is taking the vital signs of a woman who delivered a

healthy newborn infant 4 hours ago. The nurse notes that the mother’s
temperature is 100.2°F. Which of the following actions would be most
appropriate?
A. Retake the temperature in 15 minutes.
B. Notify the physician.
C. Document the findings.
D. Increase hydration by encouraging oral fluids

Correct Answer: D. Increase hydration by encouraging oral fluids.

The mother’s temperature may be taken every 4 hours while she is awake.
Temperatures up to 100.4 F (38 C) in the first 24 hours after birth are often
related to the dehydrating effects of labor. The most appropriate action is to
increase hydration by encouraging oral fluids, which should bring the
temperature to a normal reading.

3. The nurse is assessing a client who is 6 hours PP after delivering a full-term

healthy infant. The client complains to the nurse of feelings of faintness
 and dizziness. Which of the following nursing actions would be most
appropriate?
A. Obtain hemoglobin and hematocrit levels.
B. Instruct the mother to request help when getting out of bed.
C. Elevate the mother’s legs.
D. Inform the nursery room nurse to avoid bringing the newborn infant to
the mother until the feelings of lightheadedness and dizziness have
subsided.

Correct Answer: B. Instruct the mother to request help when getting out of
bed.
Orthostatic hypotension may be evident during the first 8 hours after birth.
Feelings of faintness or dizziness are signs that should caution the nurse to be
aware of the client’s safety. The nurse should advise the mother to get help the
first few times the mother gets out of bed.

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.

Correct 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. The postpartum
recovery period covers the time period from birth until approximately six to eight
weeks after delivery. This is a time of healing and rejuvenation as the mother’s
body returns to prepregnancy states.

5. The nurse is assessing the lochia on a 1 day PP patient. The nurse notes
that the lochia is red and has a foul-smelling odor. The nurse determines
that this assessment finding is:
 A. Normal.
B. Indicates the presence of infection.
C. Indicates the need for increasing oral fluids.
D. Indicates the need for increasing ambulation.

Correct Answer: B. Indicates the presence of infection.

Lochia, the discharge present after birth, is red for the first 1 to 3 days and
gradually decreases in amount. Foul-smelling or purulent lochia usually indicates
infection, and these findings are not normal. The presence of an offensive odor or
large pieces of tissue or blood clots in lochia or the absence of lochia might be a
sign of infection.

6. When performing a PP assessment on a client, the nurse notes the

presence of clots in the lochia. The nurse examines the clots and notes that
they are larger than 1 cm. Which of the following nursing actions is most
appropriate?
A. Document the findings.
B. Notify the physician.
C. Reassess the client in 2 hours.
D. Encourage increased intake of fluids.

Correct Answer: B. Notify the physician.

Normally, one may find a few small clots in the first 1 to 2 days after birth from
pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal.
The cause of these clots, such as uterine atony or retained placental fragments,
needs to be determined and treated to prevent further blood loss.

7. A nurse in a PP unit is instructing a mother regarding lochia and the

amount of expected lochia drainage. The nurse instructs the mother that
the normal amount of lochia may vary but should never exceed the need
for:
A. One peripad per day.
B. Two peripads per day.
C. Three peripads per day.
D. Eight peripads per day.
Correct Answer: D. Eight peripads per day.
The normal amount of lochia may vary with the individual but should never
exceed 4 to 8 peripads per day. The average number of peripads is 6 per day.
Postpartum hemorrhage is defined as excessive blood loss during or after the
third stage of labor. The average blood loss is 500 mL at vaginal delivery and
1000 mL at cesarean delivery.

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

Correct 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.

9. The following are the physiological maternal changes that occur during the
PP period. Select all that apply.
A. Cervical involution occurs.
B. Vaginal distention decreases slowly.
C. Fundus begins to descend into the pelvis after 24 hours.
D. Cardiac output decreases with resultant tachycardia in the first 24 hours.
E. Digestive processes slow immediately.

Correct Answers: A and C. In the PP period, cervical healing occurs rapidly

and cervical involution occurs.
After 1 week the muscle begins to regenerate and the cervix feels firm and the
external os, is the width of a pencil. The fundus begins to descent into the pelvic
cavity after 24 hours, a process known as involution.
 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.

Correct Answer: C. Changes in vital signs.

Changes in vitals indicate hypovolemia in the anesthetized PP woman with vulvar
hematoma. There may also be intermittent bleeding. Depending on the size and
location of the vulvar hematoma, urological or neurological signs and symptoms
may be present.

11. A nurse is developing a plan of care for a PP woman with a small vulvar
hematoma. The nurse includes which specific intervention in the plan
during the first 12 hours following the delivery of this client?
A. Assess vital signs every 4 hours.
B. Inform health care providers of assessment findings.
C. Measure fundal height every 4 hours.
D. Prepare an ice pack for application to the area.

Correct Answer: D. Prepare an ice pack for application to the area.

• Option D: Application of ice will reduce swelling caused by hematoma
formation in the vulvar area. During labor, a vulvar hematoma can result
from either direct or indirect injury to the soft tissue. Examples of causes of
direct injuries include episiotomy, vaginal laceration repairs, or
instrumental deliveries, while indirect injury can result from extensive
stretching of the birth canal during vaginal delivery.
 12. A new mother received epidural anesthesia during labor and had a forceps
delivery after pushing 2 hours. At 6 hours PP, her systolic blood pressure
has dropped 20 points, her diastolic BP has dropped 10 points, and her
pulse is 120 beats per minute. The client is anxious and restless. On further
assessment, a vulvar hematoma is verified. After notifying the health care
provider, the nurse immediately plans to:
A. Monitor fundal height.
B. Apply perineal pressure.
C. Prepare the client for surgery.
D. Reassure the client.

Correct Answer: C. Prepare the client for surgery.

The use of an epidural, prolonged second-stage labor and forceps delivery are
predisposing factors for hematoma formation, and a collection of up to 500 ml of
blood can occur in the vaginal area. Although the other options may be
implemented, the immediate action would be to prepare the client for surgery to
stop the bleeding.

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. Blood pressure changes from 130/88 to 124/80 mm Hg.

Correct 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.

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 mother's legs.
C. Push on the uterus to assist in expressing clots.
D. Encourage the mother to void.

Correct 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. Uterine atony refers to the corpus uteri myometrial cells inadequate
contraction in response to endogenous oxytocin that is released in the course of
delivery. Risk factors for uterine atony include prolonged labor, precipitous labor,
uterine distension (multi-fetal gestation, polyhydramnios, fetal macrosomia),
fibroid uterus, chorioamnionitis, indicated magnesium sulfate infus

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

Correct 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. Superficial thrombophlebitis is an inflammatory
disorder of superficial veins with coexistent venous thrombosis. It usually affects
lower limbs, particularly the great saphenous vein (60% to 80%) or the
small/short saphenous vein (10% to 20%).

16, A nurse is providing instructions to a mother who has been diagnosed with
mastitis. Which of the following statements, if made by the mother, indicates a
need for further teaching?
A. “I need to take antibiotics, and I should begin to feel better in 24-48 hours.”

B. “I can use analgesics to assist in alleviating some of the discomfort.”

C. “I need to wear a supportive bra to relieve the discomfort.”

D. “I need to stop breastfeeding until this condition resolves.”

Correct Answer: D. “I need to stop breastfeeding until this condition

resolves.”
In most cases, the mother can continue to breastfeed with both breasts. If the
affected breast is too sore, the mother can pump the breast gently. Regular
emptying of the breast is important to prevent abscess formation. Continuing to
fully empty the breasts has shown to decrease the duration of symptoms in
patients treated both with and without antibiotics. Patients should be
encouraged to continue to breastfeed, pump, or hand express. If the patient
stops draining the milk, further stasis occurs, and the infection will progress.

17. A postpartum (PP) client is being treated for DVT. The nurse understands that
the client’s response to treatment will be evaluated by regularly assessing the
client for:

A. Dysuria, ecchymosis, and vertigo

B. Epistaxis, hematuria, and dysuria

C. Hematuria, ecchymosis, and epistaxis

D. Hematuria, ecchymosis, and vertigo

Correct Answer: C. Hematuria, ecchymosis, and epistaxis.

The treatment for DVT is anticoagulant therapy. The nurse assesses for bleeding,
which is an adverse effect of anticoagulants. This includes hematuria, ecchymosis,
and epistaxis. Dysuria and vertigo are not associated specifically with bleeding.
The cornerstone of treatment is anticoagulation. NICE guidelines only
recommend treating proximal DVT (not distal) and those with pulmonary emboli.
In each patient, the risks of anticoagulation need to be weighed against the
benefits.

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.

Correct 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. Patients with hypovolemic shock have severe hypovolemia with
decreased peripheral perfusion. If left untreated, these patients can develop
ischemic injury of vital organs, leading to multi-system organ failure.

19. A nurse is assessing a client in the 4th stage of labor and notes that the
fundus is firm but that bleeding is excessive. The initial nursing action would be
which of the following?

A. Massage the fundus

B. Place the mother in Trendelenburg's position

C. Notify the physician

D. Record the findings

Correct Answer: C. Notify the physician

If the bleeding is excessive, the cause may be laceration of the cervix or birth
canal. Perineal trauma is an extremely common and expected complication of
vaginal birth. Lacerations can occur spontaneously or iatrogenically, as with an
episiotomy, on the perineum, cervix, vagina, and vulva.

20. A nurse is caring for a postpartum (PP) client with a diagnosis of DVT who is
receiving a continuous intravenous infusion of heparin sodium. Which of the
following laboratory results will the nurse specifically review to determine if an
effective and appropriate dose of the heparin is being delivered?

A. Prothrombin time

B. International normalized ratio

C. Activated partial thromboplastin time

D. Platelet count

Correct Answer: C. Activated partial thromboplastin time.

Anticoagulation therapy may be used to prevent the extension of thrombus by
delaying the clotting time of the blood. Activated partial thromboplastin time
should be monitored, and a heparin dose should be adjusted to maintain a
therapeutic level of 1.5 to 2.5 times the control. Anticoagulants derive their effect
by acting at different sites of the coagulation cascade. Some act directly by
enzyme inhibition, while others indirectly, by binding to antithrombin or by
preventing their synthesis from the liver (vitamin K dependent factors).

21. A nurse is preparing a list of self-care instructions for a PP client who was
diagnosed with mastitis. Which of the following instructions would be included
on the list. Select all that apply.

A. Take the prescribed antibiotics until the soreness subsides.

B. Wear a supportive bra.

C. Avoid decompression of the breasts by breastfeeding or breast pump.

D. Rest during the acute phase.

E. Continue to breastfeed if the breasts are not too sore.

Correct Answer: B, D, and E.

Mastitis is an infection of the lactating breast. Client instructions include resting
during the acute phase, maintaining a fluid intake of at least 3 L a day, and taking
analgesics to relieve discomfort. Additional supportive measures include the use
of moist heat or ice packs and wearing a supportive bra. Non-steroidal anti-
inflammatory drugs (NSAIDs) can be used for pain control. Heat applied to the
breast just before emptying can help increase milk letdown and facilitate with
emptying. Cold packs applied to the breast after emptying can help reduce
edema and pain. Providers should ensure the patient that breastfeeding with
mastitis is safe and that they should continue to do so if desired. If the patient
does not wish to continue to breastfeed, they should be counseled on the
importance of continuing to empty the breasts and taught alternative methods
such as the use of a breast pump or manual expression.

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

Correct 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. Methergine is in a group of drugs called ergot alkaloids.
It affects the smooth muscle of a woman’s uterus, improving the muscle tone as
well as the strength and timing of uterine contractions. Methergine is used just
after a baby is born, to help deliver the placenta (also called the “afterbirth”).

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

Correct 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. Patients with
coronary artery disease or risk factors for coronary artery disease (e.g., smoking,
obesity, diabetes, high cholesterol) may be more susceptible to developing
myocardial ischemia and infarction associated with methylergonovine-induced
vasospasm.

24. Which of the following factors might result in a decreased supply of

breastmilk in a postpartum (PP) mother?

A. Supplemental feedings with formula

B. Maternal diet high in vitamin C

C. An alcoholic drink

D. Frequent feedings

Correct 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. Especially in the first couple of weeks,
supplementing with formula tricks the breasts into producing less milk. “In the
early weeks, the breasts’ capacity for milk production is calibrated in response to
the amount of milk that is removed,” says lactation consultant Diana West. “If less
milk is removed, the breasts assume that less milk is needed, so the capacity is
set at a lower point.” When the baby is given formula supplements, she naturally
eats less at the breast, and the breasts respond by making less milk. If
supplementation is necessary, pumping as well as breastfeeding can help to
promote a higher volume of milk production.

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)

Correct Answer: C. Teaching how to express her breasts in a warm shower.

Teaching the client how to express her breasts in warm shower aid with let-down
and will give temporary relief. Breast engorgement is the result of increased
blood flow in the breasts in the days after the delivery of a baby. The increased
blood flow helps the breasts make ample milk, but it can also cause pain and
discomfort.