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NUR 254 Exam 1: 200 Comprehensive
Q&A With Rationales for Maternal-
Newborn & Pediatric Nursing Success
Postpartum Assessment & BUBBLE-HE
Framework
Q1: Normal Uterine Assessment
The nurse is performing a postpartum
assessment on a client who delivered vaginally
12 hours ago. The fundus is located 1 cm below
the umbilicus, midline, and firm. Lochia is
moderate rubra. What is the appropriate
nursing action?
A) Notify the healthcare provider immediately
B) Massage the fundus vigorously
C) Document the findings as normal
D) Prepare for ultrasound examination
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☑VERIFIED ☑VERIFIED ANSWER: C) Document
the findings as normal
Rationale: Normal uterine involution occurs at a
rate of 1-2 cm per day, so the fundus should be
at or slightly below the umbilicus during the
first 24 hours. A firm, midline fundus indicates
good contraction.
Q2: Boggy and Displaced Uterus
A client who is 6 hours postpartum has a boggy
uterus that is displaced to the right. What is the
nurse's priority action?
A) Administer oxytocin as ordered
B) Assist the client to void
C) Increase the IV fluid rate
D) Notify the healthcare provider
☑VERIFIED ☑VERIFIED ANSWER: B) Assist the
client to void
Rationale: A boggy uterus displaced to the right
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is a classic sign of a full bladder. A distended
bladder lifts the uterus, preventing effective
contraction and increasing the risk of
hemorrhage. The nurse should first help the
client void, then reassess the fundus.
Q3: Abnormal Bleeding with Firm Fundus
A postpartum client has saturated two perineal
pads within one hour. The fundus is firm and
midline. What should the nurse suspect?
A) Normal postpartum bleeding
B) Uterine atony
C) Lacerations of the reproductive tract
D) Retained placental fragments
☑VERIFIED ☑VERIFIED ANSWER: C)
Lacerations of the reproductive tract
Rationale: If the fundus is firm but bleeding is
heavy, the source of bleeding is likely from
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lacerations or trauma to the cervix or vagina,
not uterine atony.
Q4: Lochia Progression
The nurse is teaching a postpartum client about
lochia progression. Which statement indicates
correct understanding?
A) "Lochia rubra should change to alba within 3
days."
B) "Lochia serosa is pinkish-brown and occurs
around days 4-10."
C) "Lochia alba is bright red and lasts for 2
weeks."
D) "Lochia should stop completely by day 7."
☑VERIFIED ☑VERIFIED ANSWER: B) "Lochia
serosa is pinkish-brown and occurs around
days 4-10."
Rationale: Lochia progresses from rubra (red,
days 1-3), to serosa (pinkish-brown, days 4-10),
NUR 254 Exam 1: 200 Comprehensive
Q&A With Rationales for Maternal-
Newborn & Pediatric Nursing Success
Postpartum Assessment & BUBBLE-HE
Framework
Q1: Normal Uterine Assessment
The nurse is performing a postpartum
assessment on a client who delivered vaginally
12 hours ago. The fundus is located 1 cm below
the umbilicus, midline, and firm. Lochia is
moderate rubra. What is the appropriate
nursing action?
A) Notify the healthcare provider immediately
B) Massage the fundus vigorously
C) Document the findings as normal
D) Prepare for ultrasound examination
,2
☑VERIFIED ☑VERIFIED ANSWER: C) Document
the findings as normal
Rationale: Normal uterine involution occurs at a
rate of 1-2 cm per day, so the fundus should be
at or slightly below the umbilicus during the
first 24 hours. A firm, midline fundus indicates
good contraction.
Q2: Boggy and Displaced Uterus
A client who is 6 hours postpartum has a boggy
uterus that is displaced to the right. What is the
nurse's priority action?
A) Administer oxytocin as ordered
B) Assist the client to void
C) Increase the IV fluid rate
D) Notify the healthcare provider
☑VERIFIED ☑VERIFIED ANSWER: B) Assist the
client to void
Rationale: A boggy uterus displaced to the right
,3
is a classic sign of a full bladder. A distended
bladder lifts the uterus, preventing effective
contraction and increasing the risk of
hemorrhage. The nurse should first help the
client void, then reassess the fundus.
Q3: Abnormal Bleeding with Firm Fundus
A postpartum client has saturated two perineal
pads within one hour. The fundus is firm and
midline. What should the nurse suspect?
A) Normal postpartum bleeding
B) Uterine atony
C) Lacerations of the reproductive tract
D) Retained placental fragments
☑VERIFIED ☑VERIFIED ANSWER: C)
Lacerations of the reproductive tract
Rationale: If the fundus is firm but bleeding is
heavy, the source of bleeding is likely from
, 4
lacerations or trauma to the cervix or vagina,
not uterine atony.
Q4: Lochia Progression
The nurse is teaching a postpartum client about
lochia progression. Which statement indicates
correct understanding?
A) "Lochia rubra should change to alba within 3
days."
B) "Lochia serosa is pinkish-brown and occurs
around days 4-10."
C) "Lochia alba is bright red and lasts for 2
weeks."
D) "Lochia should stop completely by day 7."
☑VERIFIED ☑VERIFIED ANSWER: B) "Lochia
serosa is pinkish-brown and occurs around
days 4-10."
Rationale: Lochia progresses from rubra (red,
days 1-3), to serosa (pinkish-brown, days 4-10),
