NURS 404 EXAM 2 NCLEX QUESTIONS WITH
VERIFIED ANSWERS
Which patient would be most likely to have severe afterbirth pains and request a
narcotic analgesic?
a. Gravida 5, para 5
b. Primipara who delivered a 7-lb boy
c. Patient who is bottle feeding her first child
d. Patient who is breastfeeding her second child - Answers - ANS: A
The discomfort of afterpains is more acute for multiparas because repeated stretching
of muscle fibers leads to loss of uterine muscle tone. The uterus of a primipara tends to
remain contracted. Afterpains are particularly severe during breastfeeding, not bottle
feeding. The non-nursing mother may have engorgement problems that will cause her
discomfort. The patient who is nursing her second child will have more afterpains than
her first pregnancy; however, they will not be as severe as the grand multiparous
patient.
Which maternal event is abnormal in the early postpartal period?
a. Diuresis and diaphoresis
b. Flatulence and constipation
c. Extreme hunger and thirst
d. Lochial color changes from rubra to alba - Answers - ANS: D
For the first 3 days after childbirth, lochia is termed rubra. Lochia serosa follows, and
then at about 11 days, the discharge becomes clear, colorless, or white. The body rids
itself of increased plasma volume. Urine output of 3000 mL/day is common for the first
few days after birth and is facilitated by hormonal changes in the mother. Bowel tone
remains sluggish for days. Many women anticipate pain during defecation and are
unwilling to exert pressure on the perineum. The new mother is hungry because of
energy used in labor and thirsty because of fluid restrictions during labor.
Which fundal assessment finding at 12 hours after birth requires further assessment?
a. The fundus is palpable at the level of the umbilicus.
b. The fundus is palpable two fingerbreadths above the umbilicus.
c. The fundus is palpable one fingerbreadth below the umbilicus.
d. The fundus is palpable two fingerbreadths below the umbilicus. - Answers - ANS: B
The fundus rises to the umbilicus after birth and remains there for about 24 hours. A
fundus that is above the umbilicus may indicate uterine atony or urinary retention. The
fundus palpable at the umbilicus is an appropriate assessment finding for 12 hours
postpartum. The fundus palpable one fingerbreadth below the umbilicus is an
appropriate assessment finding for 12 hours postpartum. The fundus palpable two
,fingerbreadths below the umbilicus is an unusual finding for 12 hours postpartum;
however, it is still appropriate.
If the patient's white blood cell (WBC) count is 25,000/mm3 on her second postpartum
day, which action should the nurse take?
a. Document the finding.
b. Inform the health care provider.
c. Begin antibiotic therapy immediately.
d. Have the laboratory draw blood for reanalysis. - Answers - ANS: A
An increase in WBC count to 25,000/mm3 during the postpartum period is considered
normal and not a sign of infection. The nurse should document the finding. There is no
reason to alert the health care provider. Antibiotics are not needed because the
elevated WBCs are caused by the stress of labor and not an infectious process. There
is no need for reassessment as it is expected for the WBCs to be elevated.
Postpartal overdistention of the bladder and urinary retention can lead to which
complication?
a. Fever and increased blood pressure
b. Postpartum hemorrhage and eclampsia
c. Urinary tract infection and uterine rupture
d. Postpartum hemorrhage and urinary tract infection - Answers - ANS: D
Incomplete emptying and overdistention of the bladder can lead to urinary tract
infection. Overdistention of the bladder displaces the uterus and prevents contraction of
the uterine muscle. There is no correlation between bladder distention and blood
pressure or fever. There is no correlation between bladder distention and eclampsia.
The risk of uterine rupture decreases after the birth
A postpartum patient asks, "Will these stretch marks ever go away?" Which is the
nurse's best response?
a. "No, never."
b. "Yes, eventually."
c. "They will fade to silvery lines but won't disappear completely."
d. "They will continue to fade and should be gone by your 6-week checkup." - Answers -
ANS: C
Stretch marks never disappear altogether, but they do gradually fade to silvery lines.
Stating never is true, but more information can be added, such as the changes that will
occur with the stretch marks. Stretch marks do not disappear.
A pregnant patient asks when the dark line on her abdomen (linea nigra) will go away.
The nurse knows the pigmentation will fade after birth due to
a. increased estrogen.
b. increased progesterone.
,c. decreased human placental lactogen.
d. decreased melanocyte-stimulating hormone - Answers - ANS: D
Melanocyte-stimulating hormone increases during pregnancy and is responsible for
changes in skin pigmentation; the amount decreases after birth. Estrogen levels
decrease after birth. Progesterone levels decrease after birth. Human placental
lactogen production continues to aid in lactation. However, it does not affect
pigmentation.
Which clinical finding should the nurse suspect if the fundus is palpated on the right side
of the abdomen above the expected level?
a. Distended bladder
b. Normal involution
c. Been lying on her right side too long
d. Stretched ligaments that are unable to support the uterus - Answers - ANS: A
The presence of a full bladder will displace the uterus. A palpated fundus on the right
side of the abdomen above the expected level is not an expected finding. Position of the
patient should not alter uterine position. The problem is a full bladder displacing the
uterus.
Which situation would require the administration of Rho(D) immune globulin?
a. Mother Rh-negative, baby Rh-positive
b. Mother Rh-negative, baby Rh-negative
c. Mother Rh-positive, baby Rh-positive
d. Mother Rh-positive, baby Rh-negative - Answers - ANS: A
An Rh-negative mother delivering an Rh-positive baby may develop antibodies to fetal
cells that entered her bloodstream when the placenta separated. The Rho(D) immune
globulin works to destroy the fetal cells in the maternal circulation before sensitization
occurs. When the blood types are alike as with mother Rh-negative, baby Rh-negative,
no antibody formation would be anticipated. If the Rh-positive blood of the mother
comes in contact with the Rh-negative blood of the infant, no antibodies would develop
because the antigens are in the mother's blood, not the infant's.
If the rubella vaccine is indicated for a postpartum patient, which instructions should be
provided?
a. No specific instructions
b. Drinking plenty of fluids to prevent fever
c. Recommendation to stop breastfeeding for 24 hours after the injection
d. Explanation of the risks of becoming pregnant within 28 days following injection -
Answers - ANS: D
Potential risks to the fetus can occur if pregnancy results within 3 months after rubella
vaccine administration. The mother does need to understand potential side effects and
that pregnancy is discouraged for 3 months. The mother should be afebrile before the
, vaccine. Small amounts of the vaccine do cross the breast milk, but it is believed that
there is no need to discontinue breastfeeding.
Which measure is optimal in order to prevent abdominal distention following a cesarean
birth?
a. Rectal suppositories
b. Carbonated beverages
c. Early and frequent ambulation
d. Tightening and relaxing abdominal muscles - Answers - ANS: C
Activity can aid the movement of accumulated gas in the gastrointestinal tract. Rectal
suppositories can be helpful after distention occurs; however, do not prevent it.
Carbonated beverages may increase distention. Ambulation is the best prevention.
Abdominal strengthening will not prevent distention.
To assess fundal contraction 6 hours after cesarean birth, which technique should the
nurse utilize?
a. Assess lochial flow rather than palpating the fundus.
b. Palpate forcefully through the abdominal dressing.
c. Place hands on both sides of the abdomen and press downward.
d. Gently palpate, applying the same technique used for vaginal deliveries. - Answers -
ANS: D
Assessment of the fundus is the same for vaginal and cesarean deliveries. Forceful
palpation should never be used. The top of the fundus, not the sides, should be
palpated and massaged. Assessing lochial flow is not adequate; the fundus also needs
to be checked.
The nurse has completed a postpartum assessment on a patient who delivered 1 hour
ago. Which amount of lochia consists of a moderate amount?
a. Saturated peripad
b. 10 to 15 cm (4- to 6-inch) stain on the peripad
c. 2.5 to 10 cm (1- to 4-inch) stain on the peripad
d. Less than a 1-inch stain on the peripad - Answers - ANS: B
Because estimating the amount of lochia is difficult, nurses frequently record flow by
estimating the amount of lochia in 1 hour using the following labels: • Scant—less than
2.5 cm (1-inch) stain on the peripad • Light—less than a 10 cm (4 inch) stain •
Moderate—less than a 15 cm (6 inch) stain • Heavy—saturated peripad • Excessive—
saturated peripad in 15 minutes Determining the time interval that the peripad is in place
is also important. Lochia is less for women who have had a cesarean birth because
some of the endometrial lining is removed during surgery.
The postpartum nurse has completed discharge teaching for a patient being discharged
after an uncomplicated vaginal birth. Which statement by the patient indicates that
further teaching is necessary?
VERIFIED ANSWERS
Which patient would be most likely to have severe afterbirth pains and request a
narcotic analgesic?
a. Gravida 5, para 5
b. Primipara who delivered a 7-lb boy
c. Patient who is bottle feeding her first child
d. Patient who is breastfeeding her second child - Answers - ANS: A
The discomfort of afterpains is more acute for multiparas because repeated stretching
of muscle fibers leads to loss of uterine muscle tone. The uterus of a primipara tends to
remain contracted. Afterpains are particularly severe during breastfeeding, not bottle
feeding. The non-nursing mother may have engorgement problems that will cause her
discomfort. The patient who is nursing her second child will have more afterpains than
her first pregnancy; however, they will not be as severe as the grand multiparous
patient.
Which maternal event is abnormal in the early postpartal period?
a. Diuresis and diaphoresis
b. Flatulence and constipation
c. Extreme hunger and thirst
d. Lochial color changes from rubra to alba - Answers - ANS: D
For the first 3 days after childbirth, lochia is termed rubra. Lochia serosa follows, and
then at about 11 days, the discharge becomes clear, colorless, or white. The body rids
itself of increased plasma volume. Urine output of 3000 mL/day is common for the first
few days after birth and is facilitated by hormonal changes in the mother. Bowel tone
remains sluggish for days. Many women anticipate pain during defecation and are
unwilling to exert pressure on the perineum. The new mother is hungry because of
energy used in labor and thirsty because of fluid restrictions during labor.
Which fundal assessment finding at 12 hours after birth requires further assessment?
a. The fundus is palpable at the level of the umbilicus.
b. The fundus is palpable two fingerbreadths above the umbilicus.
c. The fundus is palpable one fingerbreadth below the umbilicus.
d. The fundus is palpable two fingerbreadths below the umbilicus. - Answers - ANS: B
The fundus rises to the umbilicus after birth and remains there for about 24 hours. A
fundus that is above the umbilicus may indicate uterine atony or urinary retention. The
fundus palpable at the umbilicus is an appropriate assessment finding for 12 hours
postpartum. The fundus palpable one fingerbreadth below the umbilicus is an
appropriate assessment finding for 12 hours postpartum. The fundus palpable two
,fingerbreadths below the umbilicus is an unusual finding for 12 hours postpartum;
however, it is still appropriate.
If the patient's white blood cell (WBC) count is 25,000/mm3 on her second postpartum
day, which action should the nurse take?
a. Document the finding.
b. Inform the health care provider.
c. Begin antibiotic therapy immediately.
d. Have the laboratory draw blood for reanalysis. - Answers - ANS: A
An increase in WBC count to 25,000/mm3 during the postpartum period is considered
normal and not a sign of infection. The nurse should document the finding. There is no
reason to alert the health care provider. Antibiotics are not needed because the
elevated WBCs are caused by the stress of labor and not an infectious process. There
is no need for reassessment as it is expected for the WBCs to be elevated.
Postpartal overdistention of the bladder and urinary retention can lead to which
complication?
a. Fever and increased blood pressure
b. Postpartum hemorrhage and eclampsia
c. Urinary tract infection and uterine rupture
d. Postpartum hemorrhage and urinary tract infection - Answers - ANS: D
Incomplete emptying and overdistention of the bladder can lead to urinary tract
infection. Overdistention of the bladder displaces the uterus and prevents contraction of
the uterine muscle. There is no correlation between bladder distention and blood
pressure or fever. There is no correlation between bladder distention and eclampsia.
The risk of uterine rupture decreases after the birth
A postpartum patient asks, "Will these stretch marks ever go away?" Which is the
nurse's best response?
a. "No, never."
b. "Yes, eventually."
c. "They will fade to silvery lines but won't disappear completely."
d. "They will continue to fade and should be gone by your 6-week checkup." - Answers -
ANS: C
Stretch marks never disappear altogether, but they do gradually fade to silvery lines.
Stating never is true, but more information can be added, such as the changes that will
occur with the stretch marks. Stretch marks do not disappear.
A pregnant patient asks when the dark line on her abdomen (linea nigra) will go away.
The nurse knows the pigmentation will fade after birth due to
a. increased estrogen.
b. increased progesterone.
,c. decreased human placental lactogen.
d. decreased melanocyte-stimulating hormone - Answers - ANS: D
Melanocyte-stimulating hormone increases during pregnancy and is responsible for
changes in skin pigmentation; the amount decreases after birth. Estrogen levels
decrease after birth. Progesterone levels decrease after birth. Human placental
lactogen production continues to aid in lactation. However, it does not affect
pigmentation.
Which clinical finding should the nurse suspect if the fundus is palpated on the right side
of the abdomen above the expected level?
a. Distended bladder
b. Normal involution
c. Been lying on her right side too long
d. Stretched ligaments that are unable to support the uterus - Answers - ANS: A
The presence of a full bladder will displace the uterus. A palpated fundus on the right
side of the abdomen above the expected level is not an expected finding. Position of the
patient should not alter uterine position. The problem is a full bladder displacing the
uterus.
Which situation would require the administration of Rho(D) immune globulin?
a. Mother Rh-negative, baby Rh-positive
b. Mother Rh-negative, baby Rh-negative
c. Mother Rh-positive, baby Rh-positive
d. Mother Rh-positive, baby Rh-negative - Answers - ANS: A
An Rh-negative mother delivering an Rh-positive baby may develop antibodies to fetal
cells that entered her bloodstream when the placenta separated. The Rho(D) immune
globulin works to destroy the fetal cells in the maternal circulation before sensitization
occurs. When the blood types are alike as with mother Rh-negative, baby Rh-negative,
no antibody formation would be anticipated. If the Rh-positive blood of the mother
comes in contact with the Rh-negative blood of the infant, no antibodies would develop
because the antigens are in the mother's blood, not the infant's.
If the rubella vaccine is indicated for a postpartum patient, which instructions should be
provided?
a. No specific instructions
b. Drinking plenty of fluids to prevent fever
c. Recommendation to stop breastfeeding for 24 hours after the injection
d. Explanation of the risks of becoming pregnant within 28 days following injection -
Answers - ANS: D
Potential risks to the fetus can occur if pregnancy results within 3 months after rubella
vaccine administration. The mother does need to understand potential side effects and
that pregnancy is discouraged for 3 months. The mother should be afebrile before the
, vaccine. Small amounts of the vaccine do cross the breast milk, but it is believed that
there is no need to discontinue breastfeeding.
Which measure is optimal in order to prevent abdominal distention following a cesarean
birth?
a. Rectal suppositories
b. Carbonated beverages
c. Early and frequent ambulation
d. Tightening and relaxing abdominal muscles - Answers - ANS: C
Activity can aid the movement of accumulated gas in the gastrointestinal tract. Rectal
suppositories can be helpful after distention occurs; however, do not prevent it.
Carbonated beverages may increase distention. Ambulation is the best prevention.
Abdominal strengthening will not prevent distention.
To assess fundal contraction 6 hours after cesarean birth, which technique should the
nurse utilize?
a. Assess lochial flow rather than palpating the fundus.
b. Palpate forcefully through the abdominal dressing.
c. Place hands on both sides of the abdomen and press downward.
d. Gently palpate, applying the same technique used for vaginal deliveries. - Answers -
ANS: D
Assessment of the fundus is the same for vaginal and cesarean deliveries. Forceful
palpation should never be used. The top of the fundus, not the sides, should be
palpated and massaged. Assessing lochial flow is not adequate; the fundus also needs
to be checked.
The nurse has completed a postpartum assessment on a patient who delivered 1 hour
ago. Which amount of lochia consists of a moderate amount?
a. Saturated peripad
b. 10 to 15 cm (4- to 6-inch) stain on the peripad
c. 2.5 to 10 cm (1- to 4-inch) stain on the peripad
d. Less than a 1-inch stain on the peripad - Answers - ANS: B
Because estimating the amount of lochia is difficult, nurses frequently record flow by
estimating the amount of lochia in 1 hour using the following labels: • Scant—less than
2.5 cm (1-inch) stain on the peripad • Light—less than a 10 cm (4 inch) stain •
Moderate—less than a 15 cm (6 inch) stain • Heavy—saturated peripad • Excessive—
saturated peripad in 15 minutes Determining the time interval that the peripad is in place
is also important. Lochia is less for women who have had a cesarean birth because
some of the endometrial lining is removed during surgery.
The postpartum nurse has completed discharge teaching for a patient being discharged
after an uncomplicated vaginal birth. Which statement by the patient indicates that
further teaching is necessary?
