NU 170 Exam 4 Review: 100 Questions,
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Maternal-Child Nursing - Postpartum & Newborn Care
SECTION 1: Postpartum Assessment & Complications (Questions 1-25)
1. A nurse is assessing a postpartum client who is 4 hours post-delivery. The
fundus is located to the right of midline and is boggy. What is the priority
nursing action?
A) Administer prescribed oxytocin
B) Massage the fundus vigorously
C) Have the client void and reassess
D) Notify the healthcare provider
Answer: C) Have the client void and reassess
Rationale: A full bladder can displace the uterus to the right or left of midline and
prevent it from contracting effectively, leading to uterine atony and postpartum
hemorrhage. The priority is to have the client empty her bladder, then reassess
fundal position and firmness. After voiding, if the fundus remains boggy, further
interventions such as fundal massage and medication administration would be
appropriate .
2. A postpartum client has a firm uterus but is experiencing a continuous trickle
of bright red blood. Which condition is the most likely cause?
,A) Uterine atony
B) Laceration of the reproductive tract
C) Hematoma
D) Retained placental fragments
Answer: B) Laceration of the reproductive tract
Rationale: A continuous trickle of bright red blood with a firm uterus is
characteristic of lacerations to the cervix, vagina, or perineum. Uterine atony
would present with a boggy uterus. Hematomas present as a bulging mass with
severe pain. Retained placental fragments typically cause late postpartum
hemorrhage .
3. Which assessment finding is most concerning in a client who is 24 hours
postpartum?
A) Temperature of 99.0°F (37.2°C)
B) Perineal pad saturated every 5 hours
C) Total urine output of 1500 mL
D) Fundus slightly firm
Answer: B) Perineal pad saturated every 5 hours
Rationale: Saturating a perineal pad every 5 hours indicates excessive bleeding
that requires immediate investigation. Normal lochia flow should gradually
decrease. A temperature of 99.0°F can be normal due to dehydration from labor.
Urine output of 1500 mL is adequate. The fundus should remain firm .
4. A postpartum client reports severe, unrelenting perineal pain that is not
relieved by analgesics. On assessment, the nurse notes a bulging, bluish-purplish
mass. What is the priority nursing intervention?
A) Apply an ice pack to the area
B) Administer stronger pain medication
C) Notify the healthcare provider immediately
D) Encourage the client to ambulate
,Answer: C) Notify the healthcare provider immediately
Rationale: These findings are consistent with a hematoma—a localized collection
of blood outside blood vessels. Hematomas cause severe, unrelenting pain that
does not respond to analgesics. This is an emergency requiring prompt medical
evaluation. Ice packs, medications, and ambulation are not appropriate until the
hematoma is evaluated .
5. What is the most common cause of early postpartum hemorrhage?
A) Retained placental fragments
B) Uterine atony
C) Genital tract lacerations
D) Hematoma formation
Answer: B) Uterine atony
Rationale: Uterine atony (failure of the uterus to contract effectively) is the most
common cause of early postpartum hemorrhage, accounting for approximately
75% of cases. Risk factors include a full bladder, uterine overdistention, prolonged
labor, and use of tocolytics .
6. A nurse is caring for a client with postpartum hemorrhage. Which medication
would the nurse anticipate administering to promote uterine contraction?
A) RhoGAM
B) Oxytocin (Pitocin)
C) Heparin
D) Magnesium sulfate
Answer: B) Oxytocin (Pitocin)
Rationale: Oxytocin is a uterotonic medication that causes the uterus to contract,
thereby controlling hemorrhage. Other medications for PPH include
methylergonovine (Methergine) for vasoconstriction and carboprost (Hemabate)
which promotes clotting. RhoGAM is for Rh incompatibility, heparin is an
anticoagulant, and magnesium sulfate is for preeclampsia .
, 7. Which finding in a postpartum client suggests the development of
endometritis?
A) Breast tenderness and warmth
B) Foul-smelling lochia and uterine tenderness
C) Painful, swollen breasts
D) Absence of lochia
Answer: B) Foul-smelling lochia and uterine tenderness
Rationale: Endometritis is an infection of the uterine lining characterized by a
tender, enlarged uterus, foul-smelling lochia, fever, and prolonged cramping.
Teaching should include proper perineal care and avoidance of douching. Breast
tenderness with warmth suggests mastitis .
8. The nurse is caring for a postpartum client who is prescribed Rho(D) immune
globulin (RhoGAM). In which situation is RhoGAM indicated?
A) Mother is Rh-positive and baby is Rh-negative
B) Mother is Rh-negative and baby is Rh-positive
C) Mother is Rh-positive and baby is Rh-positive
D) Mother is Rh-negative and baby is Rh-negative
Answer: B) Mother is Rh-negative and baby is Rh-positive
Rationale: RhoGAM is administered to Rh-negative mothers who have given birth
to Rh-positive infants. It prevents the mother from forming antibodies against Rh-
positive blood cells, which could cause hemolytic disease in future pregnancies. It
should be given during pregnancy (at 28 weeks) and within 72 hours after birth if
the baby is Rh-positive .
9. A postpartum client is in the "taking-hold phase" of maternal adaptation.
Which behavior is consistent with this phase?
A) Relies heavily on the nurse for infant care
B) Asks for information about sitz baths and perineal care
Answers(Verified Answers) Plus
Rationales 2026 -2027 Q&A Instant
Download Pdf
Maternal-Child Nursing - Postpartum & Newborn Care
SECTION 1: Postpartum Assessment & Complications (Questions 1-25)
1. A nurse is assessing a postpartum client who is 4 hours post-delivery. The
fundus is located to the right of midline and is boggy. What is the priority
nursing action?
A) Administer prescribed oxytocin
B) Massage the fundus vigorously
C) Have the client void and reassess
D) Notify the healthcare provider
Answer: C) Have the client void and reassess
Rationale: A full bladder can displace the uterus to the right or left of midline and
prevent it from contracting effectively, leading to uterine atony and postpartum
hemorrhage. The priority is to have the client empty her bladder, then reassess
fundal position and firmness. After voiding, if the fundus remains boggy, further
interventions such as fundal massage and medication administration would be
appropriate .
2. A postpartum client has a firm uterus but is experiencing a continuous trickle
of bright red blood. Which condition is the most likely cause?
,A) Uterine atony
B) Laceration of the reproductive tract
C) Hematoma
D) Retained placental fragments
Answer: B) Laceration of the reproductive tract
Rationale: A continuous trickle of bright red blood with a firm uterus is
characteristic of lacerations to the cervix, vagina, or perineum. Uterine atony
would present with a boggy uterus. Hematomas present as a bulging mass with
severe pain. Retained placental fragments typically cause late postpartum
hemorrhage .
3. Which assessment finding is most concerning in a client who is 24 hours
postpartum?
A) Temperature of 99.0°F (37.2°C)
B) Perineal pad saturated every 5 hours
C) Total urine output of 1500 mL
D) Fundus slightly firm
Answer: B) Perineal pad saturated every 5 hours
Rationale: Saturating a perineal pad every 5 hours indicates excessive bleeding
that requires immediate investigation. Normal lochia flow should gradually
decrease. A temperature of 99.0°F can be normal due to dehydration from labor.
Urine output of 1500 mL is adequate. The fundus should remain firm .
4. A postpartum client reports severe, unrelenting perineal pain that is not
relieved by analgesics. On assessment, the nurse notes a bulging, bluish-purplish
mass. What is the priority nursing intervention?
A) Apply an ice pack to the area
B) Administer stronger pain medication
C) Notify the healthcare provider immediately
D) Encourage the client to ambulate
,Answer: C) Notify the healthcare provider immediately
Rationale: These findings are consistent with a hematoma—a localized collection
of blood outside blood vessels. Hematomas cause severe, unrelenting pain that
does not respond to analgesics. This is an emergency requiring prompt medical
evaluation. Ice packs, medications, and ambulation are not appropriate until the
hematoma is evaluated .
5. What is the most common cause of early postpartum hemorrhage?
A) Retained placental fragments
B) Uterine atony
C) Genital tract lacerations
D) Hematoma formation
Answer: B) Uterine atony
Rationale: Uterine atony (failure of the uterus to contract effectively) is the most
common cause of early postpartum hemorrhage, accounting for approximately
75% of cases. Risk factors include a full bladder, uterine overdistention, prolonged
labor, and use of tocolytics .
6. A nurse is caring for a client with postpartum hemorrhage. Which medication
would the nurse anticipate administering to promote uterine contraction?
A) RhoGAM
B) Oxytocin (Pitocin)
C) Heparin
D) Magnesium sulfate
Answer: B) Oxytocin (Pitocin)
Rationale: Oxytocin is a uterotonic medication that causes the uterus to contract,
thereby controlling hemorrhage. Other medications for PPH include
methylergonovine (Methergine) for vasoconstriction and carboprost (Hemabate)
which promotes clotting. RhoGAM is for Rh incompatibility, heparin is an
anticoagulant, and magnesium sulfate is for preeclampsia .
, 7. Which finding in a postpartum client suggests the development of
endometritis?
A) Breast tenderness and warmth
B) Foul-smelling lochia and uterine tenderness
C) Painful, swollen breasts
D) Absence of lochia
Answer: B) Foul-smelling lochia and uterine tenderness
Rationale: Endometritis is an infection of the uterine lining characterized by a
tender, enlarged uterus, foul-smelling lochia, fever, and prolonged cramping.
Teaching should include proper perineal care and avoidance of douching. Breast
tenderness with warmth suggests mastitis .
8. The nurse is caring for a postpartum client who is prescribed Rho(D) immune
globulin (RhoGAM). In which situation is RhoGAM indicated?
A) Mother is Rh-positive and baby is Rh-negative
B) Mother is Rh-negative and baby is Rh-positive
C) Mother is Rh-positive and baby is Rh-positive
D) Mother is Rh-negative and baby is Rh-negative
Answer: B) Mother is Rh-negative and baby is Rh-positive
Rationale: RhoGAM is administered to Rh-negative mothers who have given birth
to Rh-positive infants. It prevents the mother from forming antibodies against Rh-
positive blood cells, which could cause hemolytic disease in future pregnancies. It
should be given during pregnancy (at 28 weeks) and within 72 hours after birth if
the baby is Rh-positive .
9. A postpartum client is in the "taking-hold phase" of maternal adaptation.
Which behavior is consistent with this phase?
A) Relies heavily on the nurse for infant care
B) Asks for information about sitz baths and perineal care
