,1. A nurse is assessing a postpartum patient who delivered 12 hours ago. The fundus is located
1 cm above the umbilicus and is deviated to the right. The patient reports increased pain and a
full sensation in her lower abdomen. What is the nurse's priority action?
A) Massage the fundus firmly until it becomes firm.
B) Notify the healthcare provider of a potential uterine infection.
C) Assist the patient to the bathroom to void.
D) Document the findings as a normal postpartum assessment.
Correct Answer: Assist the patient to the bathroom to void.
Rationale: A fundus that is elevated and deviated to the right, along with increased pain and a
full sensation, is a classic sign of a distended bladder. A full bladder displaces the uterus and
prevents it from contracting effectively, increasing the risk of postpartum hemorrhage. The
priority intervention is to have the patient void, which will allow the uterus to descend and
contract properly.
2. A nurse is providing discharge teaching to a postpartum patient. The patient asks, "How long
will I have the red bleeding?" Which response by the nurse is accurate regarding the expected
progression of lochia?
A) "You will have bright red bleeding for about 10 to 14 days."
B) "The red bleeding will change to a pinkish-brown color around day 4 or 5."
C) "It is normal to have heavy, bright red bleeding for up to 3 weeks."
D) "You can expect the bleeding to stop completely within 3 to 4 days."
Correct Answer: "The red bleeding will change to a pinkish-brown color around day 4 or 5."
Rationale: Lochia rubra is the first stage of vaginal discharge after birth and is bright red, lasting
approximately 1 to 3 days . After this, lochia serosa, which is pinkish-brown, typically lasts from
,day 4 to 10 . The final stage is lochia alba, a whitish-yellow discharge that can last from 10 to 14
days and up to 6 weeks .
3. A 3-day-old newborn has a yellow discoloration of the skin and sclera. The nurse understands
that this condition is most likely due to which of the following?
A) Normal physiological jaundice related to immature liver function.
B) A blood group incompatibility between the mother and newborn.
C) A birth injury causing bruising and red blood cell breakdown.
D) An infection that requires immediate antibiotic therapy.
Correct Answer: Normal physiological jaundice related to immature liver function.
Rationale: Physiological jaundice is a common, benign condition in newborns that typically
appears after the first 24 hours of life. It is caused by the immature liver's inability to conjugate
and excrete bilirubin efficiently, which is exacerbated by the breakdown of fetal red blood cells.
This is a normal transitional adaptation and usually resolves without treatment. Pathological
jaundice occurs within the first 24 hours and is more concerning.
4. A nurse is assessing the four mechanisms of heat loss in a newborn. The nurse places the
newborn on a warmed radiant warmer, which prevents heat loss through which mechanism?
A) Conduction
B) Convection
C) Evaporation
D) Radiation
Correct Answer: Conduction
, Rationale: Conduction is the loss of body heat to a cooler surface that is in direct contact with
the newborn . Placing a newborn on a warmed radiant warmer prevents heat loss via
conduction. Convection is heat loss from moving air currents, evaporation is heat loss from wet
skin, and radiation is heat loss to cooler surfaces not in direct contact .
5. A postpartum patient who is Rh-negative and has an Rh-positive newborn should receive Rh
immune globulin (RhoGAM) within which timeframe to prevent isoimmunization?
A) Within 24 hours of delivery
B) Within 48 hours of delivery
C) Within 72 hours of delivery
D) Within 1 week of delivery
Correct Answer: Within 72 hours of delivery
Rationale: Rh immune globulin (RhoGAM) is administered to Rh-negative mothers who have an
Rh-positive infant to prevent maternal sensitization to Rh-positive blood cells from the fetus . It
must be given within 72 hours of delivery to be effective . It is also given at 28 weeks gestation
and after any invasive procedure that could cause fetomaternal bleeding.
6. A 16-month-old toddler is brought to the clinic for a well-child visit. According to Erikson's
stages of psychosocial development, the nurse should plan care that promotes which
developmental task?
A) Trust versus Mistrust
B) Autonomy versus Shame and Doubt
C) Initiative versus Guilt
D) Industry versus Inferiority
Correct Answer: Autonomy versus Shame and Doubt
1 cm above the umbilicus and is deviated to the right. The patient reports increased pain and a
full sensation in her lower abdomen. What is the nurse's priority action?
A) Massage the fundus firmly until it becomes firm.
B) Notify the healthcare provider of a potential uterine infection.
C) Assist the patient to the bathroom to void.
D) Document the findings as a normal postpartum assessment.
Correct Answer: Assist the patient to the bathroom to void.
Rationale: A fundus that is elevated and deviated to the right, along with increased pain and a
full sensation, is a classic sign of a distended bladder. A full bladder displaces the uterus and
prevents it from contracting effectively, increasing the risk of postpartum hemorrhage. The
priority intervention is to have the patient void, which will allow the uterus to descend and
contract properly.
2. A nurse is providing discharge teaching to a postpartum patient. The patient asks, "How long
will I have the red bleeding?" Which response by the nurse is accurate regarding the expected
progression of lochia?
A) "You will have bright red bleeding for about 10 to 14 days."
B) "The red bleeding will change to a pinkish-brown color around day 4 or 5."
C) "It is normal to have heavy, bright red bleeding for up to 3 weeks."
D) "You can expect the bleeding to stop completely within 3 to 4 days."
Correct Answer: "The red bleeding will change to a pinkish-brown color around day 4 or 5."
Rationale: Lochia rubra is the first stage of vaginal discharge after birth and is bright red, lasting
approximately 1 to 3 days . After this, lochia serosa, which is pinkish-brown, typically lasts from
,day 4 to 10 . The final stage is lochia alba, a whitish-yellow discharge that can last from 10 to 14
days and up to 6 weeks .
3. A 3-day-old newborn has a yellow discoloration of the skin and sclera. The nurse understands
that this condition is most likely due to which of the following?
A) Normal physiological jaundice related to immature liver function.
B) A blood group incompatibility between the mother and newborn.
C) A birth injury causing bruising and red blood cell breakdown.
D) An infection that requires immediate antibiotic therapy.
Correct Answer: Normal physiological jaundice related to immature liver function.
Rationale: Physiological jaundice is a common, benign condition in newborns that typically
appears after the first 24 hours of life. It is caused by the immature liver's inability to conjugate
and excrete bilirubin efficiently, which is exacerbated by the breakdown of fetal red blood cells.
This is a normal transitional adaptation and usually resolves without treatment. Pathological
jaundice occurs within the first 24 hours and is more concerning.
4. A nurse is assessing the four mechanisms of heat loss in a newborn. The nurse places the
newborn on a warmed radiant warmer, which prevents heat loss through which mechanism?
A) Conduction
B) Convection
C) Evaporation
D) Radiation
Correct Answer: Conduction
, Rationale: Conduction is the loss of body heat to a cooler surface that is in direct contact with
the newborn . Placing a newborn on a warmed radiant warmer prevents heat loss via
conduction. Convection is heat loss from moving air currents, evaporation is heat loss from wet
skin, and radiation is heat loss to cooler surfaces not in direct contact .
5. A postpartum patient who is Rh-negative and has an Rh-positive newborn should receive Rh
immune globulin (RhoGAM) within which timeframe to prevent isoimmunization?
A) Within 24 hours of delivery
B) Within 48 hours of delivery
C) Within 72 hours of delivery
D) Within 1 week of delivery
Correct Answer: Within 72 hours of delivery
Rationale: Rh immune globulin (RhoGAM) is administered to Rh-negative mothers who have an
Rh-positive infant to prevent maternal sensitization to Rh-positive blood cells from the fetus . It
must be given within 72 hours of delivery to be effective . It is also given at 28 weeks gestation
and after any invasive procedure that could cause fetomaternal bleeding.
6. A 16-month-old toddler is brought to the clinic for a well-child visit. According to Erikson's
stages of psychosocial development, the nurse should plan care that promotes which
developmental task?
A) Trust versus Mistrust
B) Autonomy versus Shame and Doubt
C) Initiative versus Guilt
D) Industry versus Inferiority
Correct Answer: Autonomy versus Shame and Doubt
