NURSING NUR 254
Exam
Inside you will find:
Answer options (A–D)
Correct Answer
Clear explanation/rationale
Maternal Section
1. A nurse is assessing a client who delivered vaginally 2 days ago. The
client’s temperature is 99°F (37.2°C), pulse is 56/min, respiratory rate is
18/min, and blood pressure is 160/100 mmHg.
Which finding requires immediate follow-up?
A. Temperature 99°F (37.2°C)
B. Pulse 56/min
C. Respiratory rate 18/min
D. Blood pressure 160/100 mmHg
,✅ Correct Answer: D
Explanation: Postpartum hypertension is abnormal and could indicate
preeclampsia or eclampsia. Bradycardia and mild low-grade fever can be
normal in the immediate postpartum period.
2. A nurse is caring for a client on postpartum day 4 who asks what kind
of vaginal bleeding to expect. The nurse reviews the peripad and notes
pink-brown discharge.
Which lochia type should the nurse document?
A. Rubra, dark red, heavy
B. Serosa, pink-brown, moderate
C. Alba, white, scant
D. Rubra, bright red, scant
✅ Correct Answer: B
Explanation: Lochia serosa is expected between days 4–10 and appears
pink to brown. Lochia rubra occurs days 1–3 and alba begins around day
10.
3. A nurse palpates the fundus of a client who is 2 days postpartum and
finds it firm, midline, and 2 cm below the umbilicus.
What is the best interpretation of this finding?
A. Normal uterine involution
B. Subinvolution of the uterus
C. Retained placental fragments
D. Uterine atony
✅ Correct Answer: A
Explanation: The uterus normally descends about 1 cm per day after
delivery. By day 2, the fundus should be approximately 2 cm below the
umbilicus.
, 4. A nurse is completing a postpartum assessment using the BUBBLE-
HE framework. The nurse focuses on the “HE” portion of the
assessment.
Which complication is being evaluated?
A. Breast engorgement
B. Lochia changes
C. Thrombophlebitis
D. Emotional adjustment
✅ Correct Answer: C
Explanation: “HE” refers to Homan’s sign and Extremities, focusing on
circulation and thrombophlebitis risk.
5. A client, 6 hours postpartum, calls the nurse stating she has soaked
through two pads in 30 minutes and is passing large clots.
What is the nurse’s priority action?
A. Document as expected lochia
B. Assess for signs of infection
C. Evaluate for postpartum hemorrhage
D. Reassure the client this is normal
✅ Correct Answer: C
Explanation: Saturating pads quickly with clots indicates postpartum
hemorrhage and is never normal. Immediate assessment and intervention
are required.
6. A nurse is assessing a client with a postpartum infection. The nurse
notes foul-smelling lochia and a fever of 102°F (38.9°C).
Which complication does this most likely indicate?
A. Mastitis
Exam
Inside you will find:
Answer options (A–D)
Correct Answer
Clear explanation/rationale
Maternal Section
1. A nurse is assessing a client who delivered vaginally 2 days ago. The
client’s temperature is 99°F (37.2°C), pulse is 56/min, respiratory rate is
18/min, and blood pressure is 160/100 mmHg.
Which finding requires immediate follow-up?
A. Temperature 99°F (37.2°C)
B. Pulse 56/min
C. Respiratory rate 18/min
D. Blood pressure 160/100 mmHg
,✅ Correct Answer: D
Explanation: Postpartum hypertension is abnormal and could indicate
preeclampsia or eclampsia. Bradycardia and mild low-grade fever can be
normal in the immediate postpartum period.
2. A nurse is caring for a client on postpartum day 4 who asks what kind
of vaginal bleeding to expect. The nurse reviews the peripad and notes
pink-brown discharge.
Which lochia type should the nurse document?
A. Rubra, dark red, heavy
B. Serosa, pink-brown, moderate
C. Alba, white, scant
D. Rubra, bright red, scant
✅ Correct Answer: B
Explanation: Lochia serosa is expected between days 4–10 and appears
pink to brown. Lochia rubra occurs days 1–3 and alba begins around day
10.
3. A nurse palpates the fundus of a client who is 2 days postpartum and
finds it firm, midline, and 2 cm below the umbilicus.
What is the best interpretation of this finding?
A. Normal uterine involution
B. Subinvolution of the uterus
C. Retained placental fragments
D. Uterine atony
✅ Correct Answer: A
Explanation: The uterus normally descends about 1 cm per day after
delivery. By day 2, the fundus should be approximately 2 cm below the
umbilicus.
, 4. A nurse is completing a postpartum assessment using the BUBBLE-
HE framework. The nurse focuses on the “HE” portion of the
assessment.
Which complication is being evaluated?
A. Breast engorgement
B. Lochia changes
C. Thrombophlebitis
D. Emotional adjustment
✅ Correct Answer: C
Explanation: “HE” refers to Homan’s sign and Extremities, focusing on
circulation and thrombophlebitis risk.
5. A client, 6 hours postpartum, calls the nurse stating she has soaked
through two pads in 30 minutes and is passing large clots.
What is the nurse’s priority action?
A. Document as expected lochia
B. Assess for signs of infection
C. Evaluate for postpartum hemorrhage
D. Reassure the client this is normal
✅ Correct Answer: C
Explanation: Saturating pads quickly with clots indicates postpartum
hemorrhage and is never normal. Immediate assessment and intervention
are required.
6. A nurse is assessing a client with a postpartum infection. The nurse
notes foul-smelling lochia and a fever of 102°F (38.9°C).
Which complication does this most likely indicate?
A. Mastitis
