NUR 254 EXAM 2 | 50 Questions and Answers
| 2025 Update | 100% Correct-Galen College of
Nursing.
Section I: Postpartum Assessment & Complications (Questions 1–35)
Question 1
A nurse is assessing a client who is 24 hours postpartum. Which finding requires immediate
follow-up?
A) Fundus firm, 1 cm below umbilicus
B) Saturating one perineal pad every hour
C) Lochia rubra with small clots
D) Perineal discomfort rated 3/10
Correct Answer: B
Rationale: Saturating one pad per hour for more than one hour indicates excessive bleeding
and possible postpartum hemorrhage. A firm fundus at 1 cm below the umbilicus is a normal
finding at 24 hours postpartum. Lochia rubra with small clots is expected in the first 1–3 days.
Perineal discomfort is a normal postpartum finding.
Question 2
A nurse is assessing a postpartum client who delivered 2 hours ago. The nurse notes the fundus
is boggy, above the umbilicus, and deviated to the right. Which action should the nurse take
first?
A) Massage the fundus
B) Assist the client to empty her bladder
C) Administer oxytocin as prescribed
D) Notify the provider
Correct Answer: B
Rationale: A boggy uterus that is deviated to the right indicates a distended bladder is
displacing the uterus and preventing it from contracting. The first intervention is to empty the
bladder, which will allow the uterus to contract and return to midline. Massaging the fundus is
,appropriate once the bladder is empty. Medications and provider notification follow if these
measures are unsuccessful.
Question 3
A nurse is providing education to a postpartum client about expected involution changes. Which
statement by the client indicates understanding?
A) "My uterus should return to its pre-pregnancy size within 2 weeks."
B) "The uterus should not be palpable abdominally by 2 weeks postpartum."
C) "The fundus should rise 1–2 cm each day after delivery."
D) "The uterus should remain at the umbilicus for the first week."
Correct Answer: B
Rationale: Uterine involution progresses at approximately 1–2 cm per day, and the uterus
should no longer be palpable abdominally by approximately 2 weeks postpartum. The fundus
descends (not rises) after delivery. The uterus should not remain at the umbilicus for a week.
Question 4
Select All That Apply: A nurse is assessing a postpartum client for signs of infection. Which
findings should the nurse report?
A) Temperature 100.8°F on the first postpartum day
B) WBC count of 14,000/mm³
C) Heart rate of 110 beats/minute
D) Lochia with foul odor
E) Temperature 101.2°F on the third postpartum day
Correct Answers: A, C, D, E
Rationale: Postpartum infection is suggested by temperature >100.4°F, heart rate >100
beats/minute, and foul-smelling lochia. A WBC count of 14,000/mm³ can be a normal
postpartum finding due to physiological leukocytosis. Temperature of 100.8°F on day 1 warrants
monitoring, and 101.2°F on day 3 is concerning for infection.
Question 5
,A nurse is assessing lochia in a client who is 5 days postpartum. Which description is expected?
A) Bright red with large clots
B) Pinkish-brown
C) White-yellow
D) Dark red with moderate flow
Correct Answer: B
Rationale: Lochia serosa occurs from days 4–10 postpartum and is pinkish-brown in color.
Lochia rubra (bright red) occurs days 1–3. Lochia alba (white-yellow) occurs days 10–14 and
beyond.
Question 6
A nurse is caring for a client who had a cesarean birth 6 hours ago. The nurse notes the client's
dressing has a small amount of serosanguineous drainage. Which action is appropriate?
A) Reinforce the dressing and document the finding
B) Change the dressing immediately
C) Notify the provider for wound dehiscence
D) Mark the drainage and reassess in 4 hours
Correct Answer: A
Rationale: A small amount of serosanguineous drainage is expected post-cesarean. The
nurse should reinforce the dressing (not change it, as this increases infection risk) and
document the finding. Marking the drainage and reassessing is also appropriate but reinforcing
and documenting is the immediate action.
Question 7
A nurse is teaching a postpartum client about signs of deep vein thrombosis (DVT). Which
symptom should the client report immediately?
A) Bilateral ankle swelling
B) Unilateral calf pain and warmth
C) Generalized fatigue
D) Mild shortness of breath with activity
Correct Answer: B
, Rationale: Unilateral calf pain, warmth, and swelling are classic signs of DVT. Bilateral
swelling is more common with fluid retention or preeclampsia. DVT is a serious complication
requiring immediate intervention due to risk of pulmonary embolism.
Question 8
A nurse is assessing a client who is 12 hours postpartum. The nurse notes the uterus is firm at
the umbilicus, and there is a continuous trickle of bright red blood. Which action should the
nurse take first?
A) Document the finding as normal
B) Assess for cervical or vaginal lacerations
C) Massage the uterus vigorously
D) Increase the oxytocin infusion rate
Correct Answer: B
Rationale: A firm uterus with continued bright red bleeding suggests lacerations of the
cervix or vagina rather than uterine atony. Massaging a firm uterus is not indicated and could
cause trauma. The nurse should assess for lacerations and notify the provider.
Question 9
A nurse is caring for a client who is 2 days postpartum and reports breast engorgement. Which
intervention should the nurse recommend?
A) Apply cold compresses between feedings
B) Avoid breastfeeding until engorgement resolves
C) Apply warm compresses and massage before feeding
D) Restrict fluid intake
Correct Answer: C
Rationale: For engorgement, warm compresses and massage before feeding help milk flow.
Cold compresses between feedings reduce swelling and pain. Continuing to breastfeed or pump
is essential to empty the breasts and prevent mastitis. Fluid restriction is not appropriate.
Question 10
| 2025 Update | 100% Correct-Galen College of
Nursing.
Section I: Postpartum Assessment & Complications (Questions 1–35)
Question 1
A nurse is assessing a client who is 24 hours postpartum. Which finding requires immediate
follow-up?
A) Fundus firm, 1 cm below umbilicus
B) Saturating one perineal pad every hour
C) Lochia rubra with small clots
D) Perineal discomfort rated 3/10
Correct Answer: B
Rationale: Saturating one pad per hour for more than one hour indicates excessive bleeding
and possible postpartum hemorrhage. A firm fundus at 1 cm below the umbilicus is a normal
finding at 24 hours postpartum. Lochia rubra with small clots is expected in the first 1–3 days.
Perineal discomfort is a normal postpartum finding.
Question 2
A nurse is assessing a postpartum client who delivered 2 hours ago. The nurse notes the fundus
is boggy, above the umbilicus, and deviated to the right. Which action should the nurse take
first?
A) Massage the fundus
B) Assist the client to empty her bladder
C) Administer oxytocin as prescribed
D) Notify the provider
Correct Answer: B
Rationale: A boggy uterus that is deviated to the right indicates a distended bladder is
displacing the uterus and preventing it from contracting. The first intervention is to empty the
bladder, which will allow the uterus to contract and return to midline. Massaging the fundus is
,appropriate once the bladder is empty. Medications and provider notification follow if these
measures are unsuccessful.
Question 3
A nurse is providing education to a postpartum client about expected involution changes. Which
statement by the client indicates understanding?
A) "My uterus should return to its pre-pregnancy size within 2 weeks."
B) "The uterus should not be palpable abdominally by 2 weeks postpartum."
C) "The fundus should rise 1–2 cm each day after delivery."
D) "The uterus should remain at the umbilicus for the first week."
Correct Answer: B
Rationale: Uterine involution progresses at approximately 1–2 cm per day, and the uterus
should no longer be palpable abdominally by approximately 2 weeks postpartum. The fundus
descends (not rises) after delivery. The uterus should not remain at the umbilicus for a week.
Question 4
Select All That Apply: A nurse is assessing a postpartum client for signs of infection. Which
findings should the nurse report?
A) Temperature 100.8°F on the first postpartum day
B) WBC count of 14,000/mm³
C) Heart rate of 110 beats/minute
D) Lochia with foul odor
E) Temperature 101.2°F on the third postpartum day
Correct Answers: A, C, D, E
Rationale: Postpartum infection is suggested by temperature >100.4°F, heart rate >100
beats/minute, and foul-smelling lochia. A WBC count of 14,000/mm³ can be a normal
postpartum finding due to physiological leukocytosis. Temperature of 100.8°F on day 1 warrants
monitoring, and 101.2°F on day 3 is concerning for infection.
Question 5
,A nurse is assessing lochia in a client who is 5 days postpartum. Which description is expected?
A) Bright red with large clots
B) Pinkish-brown
C) White-yellow
D) Dark red with moderate flow
Correct Answer: B
Rationale: Lochia serosa occurs from days 4–10 postpartum and is pinkish-brown in color.
Lochia rubra (bright red) occurs days 1–3. Lochia alba (white-yellow) occurs days 10–14 and
beyond.
Question 6
A nurse is caring for a client who had a cesarean birth 6 hours ago. The nurse notes the client's
dressing has a small amount of serosanguineous drainage. Which action is appropriate?
A) Reinforce the dressing and document the finding
B) Change the dressing immediately
C) Notify the provider for wound dehiscence
D) Mark the drainage and reassess in 4 hours
Correct Answer: A
Rationale: A small amount of serosanguineous drainage is expected post-cesarean. The
nurse should reinforce the dressing (not change it, as this increases infection risk) and
document the finding. Marking the drainage and reassessing is also appropriate but reinforcing
and documenting is the immediate action.
Question 7
A nurse is teaching a postpartum client about signs of deep vein thrombosis (DVT). Which
symptom should the client report immediately?
A) Bilateral ankle swelling
B) Unilateral calf pain and warmth
C) Generalized fatigue
D) Mild shortness of breath with activity
Correct Answer: B
, Rationale: Unilateral calf pain, warmth, and swelling are classic signs of DVT. Bilateral
swelling is more common with fluid retention or preeclampsia. DVT is a serious complication
requiring immediate intervention due to risk of pulmonary embolism.
Question 8
A nurse is assessing a client who is 12 hours postpartum. The nurse notes the uterus is firm at
the umbilicus, and there is a continuous trickle of bright red blood. Which action should the
nurse take first?
A) Document the finding as normal
B) Assess for cervical or vaginal lacerations
C) Massage the uterus vigorously
D) Increase the oxytocin infusion rate
Correct Answer: B
Rationale: A firm uterus with continued bright red bleeding suggests lacerations of the
cervix or vagina rather than uterine atony. Massaging a firm uterus is not indicated and could
cause trauma. The nurse should assess for lacerations and notify the provider.
Question 9
A nurse is caring for a client who is 2 days postpartum and reports breast engorgement. Which
intervention should the nurse recommend?
A) Apply cold compresses between feedings
B) Avoid breastfeeding until engorgement resolves
C) Apply warm compresses and massage before feeding
D) Restrict fluid intake
Correct Answer: C
Rationale: For engorgement, warm compresses and massage before feeding help milk flow.
Cold compresses between feedings reduce swelling and pain. Continuing to breastfeed or pump
is essential to empty the breasts and prevent mastitis. Fluid restriction is not appropriate.
Question 10
