Postpartum NCLEX(Completely solved)
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
answers 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.
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 answers 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.
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 answers 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.
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 answers 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.
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 answers 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.
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 answers 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.
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 answers 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.
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 answers 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.
Select all of the physiological maternal changes that occur during the PP period.
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.
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 answers 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.
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.
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
answers 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.
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 answers 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.
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 answers 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.
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 answers 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.
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 answers 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.
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 answers 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.
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 answers 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.
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 answers 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.
Select all of the physiological maternal changes that occur during the PP period.
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.
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 answers 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.
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.
