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NUR 254 Exam 2 Postpartum Nursing: 200
Verified Questions & Answers with Detailed
Rationales Covering Assessment,
Complications, Pharmacology, Newborn
Transition, and Discharge Teaching (2026 Galen
College Resource
SECTION 1: POSTPARTUM ASSESSMENT &
BUBBLE-HE (Questions 1-15)
Q1. The nurse is performing a postpartum
assessment on a client who delivered 8 hours
ago. The fundus is firm, at the umbilicus, and
deviated to the right. What is the nurse's
priority action?
A) Document the findings as normal
B) Massage the fundus vigorously
C) Assist the client to void
,2
D) Notify the provider immediately
☑VERIFIED ANSWER: C) Assist the client to
void
Rationale: A fundus deviated to the right (or
left) is a classic sign of a distended bladder. A
full bladder displaces the uterus and prevents
adequate contraction. The priority is to have
the client void; after voiding, the fundus should
return to the midline.
Q2. The nurse assesses a client's lochia on day
2 postpartum. It is moderate in amount, dark
red in color, and contains small clots. How
should the nurse document this finding?
A) Lochia alba
B) Lochia serosa
C) Lochia rubra
D) Abnormal hemorrhage
,3
☑VERIFIED ANSWER: C) Lochia rubra
Rationale: Lochia rubra is the first stage of
lochia, lasting from delivery through days 3-4. It
is composed of blood, decidual tissue, and
mucus, giving it a dark red color. Lochia serosa
is pinkish-brown (days 4-10), and lochia alba is
yellowish-white (days 10-14+).
Q3. In the BUBBLE-HE acronym, what does the
second "B" stand for?
A) Breasts
B) Bowels
C) Bladder
D) Baby
☑VERIFIED ANSWER: C) Bladder
Rationale: BUBBLE-HE stands for Breasts,
Uterus, Bladder, Bowels, Lochia,
Episiotomy/perineum, Homan's sign (legs), and
, 4
Emotional status. The bladder must be assessed
because distention can cause uterine atony and
hemorrhage.
Q4. A client who is 12 hours postpartum has a
fundus that is 2 fingerbreadths above the
umbilicus and boggy. What is the nurse's
immediate action?
A) Document the finding and recheck in 1 hour
B) Gently massage the fundus until firm
C) Apply a cold pack to the abdomen
D) Administer a stool softener
☑VERIFIED ANSWER: B) Gently massage the
fundus until firm
Rationale: A boggy (soft) fundus above the
umbilicus indicates uterine atony. The priority is
to massage the fundus gently to stimulate
contraction and prevent postpartum
NUR 254 Exam 2 Postpartum Nursing: 200
Verified Questions & Answers with Detailed
Rationales Covering Assessment,
Complications, Pharmacology, Newborn
Transition, and Discharge Teaching (2026 Galen
College Resource
SECTION 1: POSTPARTUM ASSESSMENT &
BUBBLE-HE (Questions 1-15)
Q1. The nurse is performing a postpartum
assessment on a client who delivered 8 hours
ago. The fundus is firm, at the umbilicus, and
deviated to the right. What is the nurse's
priority action?
A) Document the findings as normal
B) Massage the fundus vigorously
C) Assist the client to void
,2
D) Notify the provider immediately
☑VERIFIED ANSWER: C) Assist the client to
void
Rationale: A fundus deviated to the right (or
left) is a classic sign of a distended bladder. A
full bladder displaces the uterus and prevents
adequate contraction. The priority is to have
the client void; after voiding, the fundus should
return to the midline.
Q2. The nurse assesses a client's lochia on day
2 postpartum. It is moderate in amount, dark
red in color, and contains small clots. How
should the nurse document this finding?
A) Lochia alba
B) Lochia serosa
C) Lochia rubra
D) Abnormal hemorrhage
,3
☑VERIFIED ANSWER: C) Lochia rubra
Rationale: Lochia rubra is the first stage of
lochia, lasting from delivery through days 3-4. It
is composed of blood, decidual tissue, and
mucus, giving it a dark red color. Lochia serosa
is pinkish-brown (days 4-10), and lochia alba is
yellowish-white (days 10-14+).
Q3. In the BUBBLE-HE acronym, what does the
second "B" stand for?
A) Breasts
B) Bowels
C) Bladder
D) Baby
☑VERIFIED ANSWER: C) Bladder
Rationale: BUBBLE-HE stands for Breasts,
Uterus, Bladder, Bowels, Lochia,
Episiotomy/perineum, Homan's sign (legs), and
, 4
Emotional status. The bladder must be assessed
because distention can cause uterine atony and
hemorrhage.
Q4. A client who is 12 hours postpartum has a
fundus that is 2 fingerbreadths above the
umbilicus and boggy. What is the nurse's
immediate action?
A) Document the finding and recheck in 1 hour
B) Gently massage the fundus until firm
C) Apply a cold pack to the abdomen
D) Administer a stool softener
☑VERIFIED ANSWER: B) Gently massage the
fundus until firm
Rationale: A boggy (soft) fundus above the
umbilicus indicates uterine atony. The priority is
to massage the fundus gently to stimulate
contraction and prevent postpartum
