1. A nurse is assessing a postpartum client 2 hours after delivery. Which of the
following findings should the nurse report immediately?
A. Fundus 1 cm above the umbilicus
B. Lochia rubra with a small clot
C. Firm, midline fundus
D. Heavy lochia with a large clot
Answer: D. Heavy lochia with a large clot
Rationale: Heavy lochia with a large clot could indicate uterine atony or hemorrhage, which
requires immediate intervention.
2. A nurse is teaching a new mother about breastfeeding. Which of the following
is a sign that the infant is effectively breastfeeding?
A. The infant sleeps for long periods after feeding
B. The infant’s tongue is positioned at the roof of the mouth
C. The infant’s cheeks are dimpled during sucking
D. The infant sucks and swallows rhythmically
Answer: D. The infant sucks and swallows rhythmically
Rationale: Effective breastfeeding is indicated by rhythmic sucking and swallowing, ensuring
proper milk intake.
3. A nurse is providing discharge instructions to a client who had a cesarean
section. Which of the following actions should the nurse instruct the client to take
to prevent postoperative complications?
A. Avoid coughing or deep breathing exercises
B. Perform abdominal exercises to strengthen the incision site
C. Use a pillow to splint the incision when coughing
D. Keep the incision site covered with a bandage at all times
Answer: C. Use a pillow to splint the incision when coughing
Rationale: Using a pillow to splint the incision helps prevent stress on the surgical site and
reduces pain when coughing or sneezing.
,4. A nurse is caring for a newborn who is 24 hours old and is experiencing
jaundice. Which of the following interventions should the nurse implement first?
A. Increase the newborn’s fluid intake
B. Initiate phototherapy
C. Encourage breastfeeding every 2 to 3 hours
D. Check bilirubin levels
Answer: C. Encourage breastfeeding every 2 to 3 hours
Rationale: Early and frequent breastfeeding helps to eliminate bilirubin through the infant’s
stools, which may help reduce jaundice.
5. A nurse is caring for a client who is 36 weeks pregnant and is experiencing
vaginal bleeding. Which of the following actions should the nurse take first?
A. Administer oxygen via face mask
B. Perform a vaginal examination
C. Assess fetal heart rate
D. Prepare the client for an ultrasound
Answer: C. Assess fetal heart rate
Rationale: Assessing fetal heart rate is the priority to determine fetal well-being, as vaginal
bleeding may indicate potential fetal distress or placental complications.
6. A nurse is assessing a postpartum client 1 day after delivery. Which of the
following findings is normal and should be expected?
A. Lochia serosa with a foul odor
B. Fundus 2 cm below the umbilicus
C. Perineal edema and bruising
D. Elevated blood pressure
Answer: C. Perineal edema and bruising
Rationale: Perineal edema and bruising are common following vaginal delivery and typically
resolve in a few days.
, 7. A nurse is caring for a client in labor who is receiving oxytocin to augment
contractions. The nurse notes that the fetal heart rate has decelerated. Which of
the following actions should the nurse take first?
A. Administer oxygen via face mask
B. Discontinue the oxytocin infusion
C. Increase the rate of IV fluids
D. Turn the client to her left side
Answer: B. Discontinue the oxytocin infusion
Rationale: Discontinuing the oxytocin infusion is the priority to reduce uterine hyperstimulation,
which could be causing fetal decelerations.
8. A nurse is assessing a 3-day-old newborn. The mother reports that the infant’s
skin appears yellow. The nurse should assess for which of the following?
A. Cyanosis
B. Meconium stool
C. Jaundice
D. Hypoglycemia
Answer: C. Jaundice
Rationale: Jaundice is common in newborns and typically appears on the second or third day of
life due to the breakdown of red blood cells.
9. A nurse is caring for a postpartum client who is experiencing perineal pain.
Which of the following interventions should the nurse implement first?
A. Apply a warm compress to the perineum
B. Administer an analgesic
C. Assist the client into a squatting position
D. Teach the client perineal hygiene measures
Answer: B. Administer an analgesic
Rationale: Pain relief should be addressed first to alleviate discomfort, allowing the client to rest
and recover.
following findings should the nurse report immediately?
A. Fundus 1 cm above the umbilicus
B. Lochia rubra with a small clot
C. Firm, midline fundus
D. Heavy lochia with a large clot
Answer: D. Heavy lochia with a large clot
Rationale: Heavy lochia with a large clot could indicate uterine atony or hemorrhage, which
requires immediate intervention.
2. A nurse is teaching a new mother about breastfeeding. Which of the following
is a sign that the infant is effectively breastfeeding?
A. The infant sleeps for long periods after feeding
B. The infant’s tongue is positioned at the roof of the mouth
C. The infant’s cheeks are dimpled during sucking
D. The infant sucks and swallows rhythmically
Answer: D. The infant sucks and swallows rhythmically
Rationale: Effective breastfeeding is indicated by rhythmic sucking and swallowing, ensuring
proper milk intake.
3. A nurse is providing discharge instructions to a client who had a cesarean
section. Which of the following actions should the nurse instruct the client to take
to prevent postoperative complications?
A. Avoid coughing or deep breathing exercises
B. Perform abdominal exercises to strengthen the incision site
C. Use a pillow to splint the incision when coughing
D. Keep the incision site covered with a bandage at all times
Answer: C. Use a pillow to splint the incision when coughing
Rationale: Using a pillow to splint the incision helps prevent stress on the surgical site and
reduces pain when coughing or sneezing.
,4. A nurse is caring for a newborn who is 24 hours old and is experiencing
jaundice. Which of the following interventions should the nurse implement first?
A. Increase the newborn’s fluid intake
B. Initiate phototherapy
C. Encourage breastfeeding every 2 to 3 hours
D. Check bilirubin levels
Answer: C. Encourage breastfeeding every 2 to 3 hours
Rationale: Early and frequent breastfeeding helps to eliminate bilirubin through the infant’s
stools, which may help reduce jaundice.
5. A nurse is caring for a client who is 36 weeks pregnant and is experiencing
vaginal bleeding. Which of the following actions should the nurse take first?
A. Administer oxygen via face mask
B. Perform a vaginal examination
C. Assess fetal heart rate
D. Prepare the client for an ultrasound
Answer: C. Assess fetal heart rate
Rationale: Assessing fetal heart rate is the priority to determine fetal well-being, as vaginal
bleeding may indicate potential fetal distress or placental complications.
6. A nurse is assessing a postpartum client 1 day after delivery. Which of the
following findings is normal and should be expected?
A. Lochia serosa with a foul odor
B. Fundus 2 cm below the umbilicus
C. Perineal edema and bruising
D. Elevated blood pressure
Answer: C. Perineal edema and bruising
Rationale: Perineal edema and bruising are common following vaginal delivery and typically
resolve in a few days.
, 7. A nurse is caring for a client in labor who is receiving oxytocin to augment
contractions. The nurse notes that the fetal heart rate has decelerated. Which of
the following actions should the nurse take first?
A. Administer oxygen via face mask
B. Discontinue the oxytocin infusion
C. Increase the rate of IV fluids
D. Turn the client to her left side
Answer: B. Discontinue the oxytocin infusion
Rationale: Discontinuing the oxytocin infusion is the priority to reduce uterine hyperstimulation,
which could be causing fetal decelerations.
8. A nurse is assessing a 3-day-old newborn. The mother reports that the infant’s
skin appears yellow. The nurse should assess for which of the following?
A. Cyanosis
B. Meconium stool
C. Jaundice
D. Hypoglycemia
Answer: C. Jaundice
Rationale: Jaundice is common in newborns and typically appears on the second or third day of
life due to the breakdown of red blood cells.
9. A nurse is caring for a postpartum client who is experiencing perineal pain.
Which of the following interventions should the nurse implement first?
A. Apply a warm compress to the perineum
B. Administer an analgesic
C. Assist the client into a squatting position
D. Teach the client perineal hygiene measures
Answer: B. Administer an analgesic
Rationale: Pain relief should be addressed first to alleviate discomfort, allowing the client to rest
and recover.
