NU 170 Exam 4 Review Questions and Answers
with Complete Solutions UPDATED!!!!.
Question 1
A nurse is assessing a client who is 4 hours postpartum. The fundus is firm at the
umbilicus and midline. The client reports severe perineal pain that is unrelieved by
analgesics. Upon inspection, the nurse notes a bluish, bulging mass on the right side of
the perineum. What is the priority nursing action?
A) Apply an ice pack to the perineum
B) Notify the healthcare provider immediately
C) Administer a warm sitz bath
D) Reassure the client that this is a normal finding
Correct Answer: B) Notify the healthcare provider immediately
Rationale: A bluish, bulging mass on the perineum accompanied by severe, unrelieved
pain is a classic sign of a perineal hematoma. This is a medical emergency requiring
immediate evaluation and possible surgical intervention. Ice packs, warm sitz baths, and
reassurance are not appropriate until the provider has been notified.
Question 2
A postpartum client is 2 days post-vaginal delivery and reports painful, swollen, and
hard breasts. She is formula-feeding her infant. What instruction should the nurse
provide?
A) Apply warm compresses to the breasts
B) Express milk frequently to relieve pressure
C) Wear a supportive, well-fitted bra
D) Massage the breasts vigorously
Correct Answer: C) Wear a supportive, well-fitted bra
Rationale: For clients who are formula-feeding, breast engorgement is managed with cold
packs, wearing a supportive bra, and avoiding breast stimulation. Warm compresses and
milk expression would stimulate further milk production and worsen engorgement.
,Question 3
A nurse is caring for a postpartum client who has heavy lochia rubra and a firm fundus.
The client is alert and oriented. What should the nurse do first?
A) Call the healthcare provider
B) Change the perineal pad
C) Palpate the bladder and have the client void if full
D) Administer oxytocin
Correct Answer: C) Palpate the bladder and have the client void if full
Rationale: A firm fundus with heavy lochia rubra may indicate that a full bladder is
displacing the uterus and preventing adequate contraction. The nurse should assess for
bladder distention and encourage voiding. This is the priority intervention before calling
the provider or administering medications.
Question 4
A nurse is assessing the fundus of a postpartum client. The fundus is located to the right
of the midline and is boggy. What is the most likely cause of this finding?
A) Uterine atony
B) Retained placental fragments
C) Full bladder
D) Infection
Correct Answer: C) Full bladder
Rationale: A boggy uterus displaced to the right of the midline is a classic sign of bladder
distention. The bladder displaces the uterus, preventing it from contracting effectively. The
nurse should have the client void and reassess the fundus. A full bladder is the most
common cause of uterine atony.
Question 5
A postpartum client who delivered vaginally 6 hours ago has a temperature of 100.4°F
(38°C). Which of the following actions should the nurse take?
,A) Continue to monitor as this is an expected finding
B) Notify the healthcare provider immediately
C) Administer acetaminophen as ordered
D) Encourage oral fluid intake
Correct Answer: A) Continue to monitor as this is an expected finding
Rationale: A temperature of up to 100.4°F (38°C) during the first 24 hours postpartum can
be a normal response to the dehydration and exertion of labor. The nurse should continue
to monitor vital signs. A temperature above 100.4°F after the first 24 hours is more
concerning and should be reported.
Question 6
A nurse is assessing a postpartum client for signs of infection. Which of the following
findings is most concerning?
A) Uterine tenderness
B) Foul-smelling lochia
C) Temperature of 99.8°F
D) Heart rate of 88 bpm
Correct Answer: B) Foul-smelling lochia
Rationale: Foul-smelling lochia is a classic sign of endometritis (infection of the uterine
lining) and requires immediate reporting and treatment. Uterine tenderness is also
concerning but may be expected with afterbirth pains. A temperature of 99.8°F is not yet a
fever (100.4°F is the threshold), and a heart rate of 88 is within normal limits.
Question 7
A nurse is caring for a postpartum client who is 1 hour post-delivery and has saturated
two perineal pads in 15 minutes. What is the priority nursing action?
A) Document the finding
B) Administer oxytocin as ordered
C) Notify the healthcare provider immediately
D) Assess the fundus and massage if boggy
, Correct Answer: D) Assess the fundus and massage if boggy
Rationale: Saturating two perineal pads in 15 minutes indicates excessive bleeding. The
nurse should first assess the fundus. If the fundus is boggy, the nurse should massage it to
stimulate contraction and reduce bleeding. If the fundus is firm, the nurse should look for
other causes such as lacerations. The provider should be notified after immediate
interventions are initiated.
Question 8
A postpartum client who is breastfeeding reports breast pain, redness, and a fever of
101.2°F (38.4°C). The nurse notes a tender, reddened area on the client's right breast.
What is the most likely diagnosis?
A) Breast engorgement
B) Mastitis
C) Plugged milk duct
D) Thrush
Correct Answer: B) Mastitis
Rationale: Mastitis is an infection of the breast tissue characterized by localized breast
pain, redness, warmth, swelling, and fever. It is most common in breastfeeding mothers
and requires antibiotic therapy. Engorgement typically presents with bilateral swelling and
discomfort without fever. A plugged duct presents with a tender lump without systemic
symptoms.
Question 9
A nurse is reinforcing teaching with a client who has mastitis. Which of the following
instructions should the nurse include? (Select all that apply)
A) Apply warm compresses to the affected breast before feeding
B) Breastfeed from the unaffected side first
C) Continue breastfeeding to empty the breast
D) Apply cold compresses after feeding
E) Discontinue breastfeeding until symptoms resolve
with Complete Solutions UPDATED!!!!.
Question 1
A nurse is assessing a client who is 4 hours postpartum. The fundus is firm at the
umbilicus and midline. The client reports severe perineal pain that is unrelieved by
analgesics. Upon inspection, the nurse notes a bluish, bulging mass on the right side of
the perineum. What is the priority nursing action?
A) Apply an ice pack to the perineum
B) Notify the healthcare provider immediately
C) Administer a warm sitz bath
D) Reassure the client that this is a normal finding
Correct Answer: B) Notify the healthcare provider immediately
Rationale: A bluish, bulging mass on the perineum accompanied by severe, unrelieved
pain is a classic sign of a perineal hematoma. This is a medical emergency requiring
immediate evaluation and possible surgical intervention. Ice packs, warm sitz baths, and
reassurance are not appropriate until the provider has been notified.
Question 2
A postpartum client is 2 days post-vaginal delivery and reports painful, swollen, and
hard breasts. She is formula-feeding her infant. What instruction should the nurse
provide?
A) Apply warm compresses to the breasts
B) Express milk frequently to relieve pressure
C) Wear a supportive, well-fitted bra
D) Massage the breasts vigorously
Correct Answer: C) Wear a supportive, well-fitted bra
Rationale: For clients who are formula-feeding, breast engorgement is managed with cold
packs, wearing a supportive bra, and avoiding breast stimulation. Warm compresses and
milk expression would stimulate further milk production and worsen engorgement.
,Question 3
A nurse is caring for a postpartum client who has heavy lochia rubra and a firm fundus.
The client is alert and oriented. What should the nurse do first?
A) Call the healthcare provider
B) Change the perineal pad
C) Palpate the bladder and have the client void if full
D) Administer oxytocin
Correct Answer: C) Palpate the bladder and have the client void if full
Rationale: A firm fundus with heavy lochia rubra may indicate that a full bladder is
displacing the uterus and preventing adequate contraction. The nurse should assess for
bladder distention and encourage voiding. This is the priority intervention before calling
the provider or administering medications.
Question 4
A nurse is assessing the fundus of a postpartum client. The fundus is located to the right
of the midline and is boggy. What is the most likely cause of this finding?
A) Uterine atony
B) Retained placental fragments
C) Full bladder
D) Infection
Correct Answer: C) Full bladder
Rationale: A boggy uterus displaced to the right of the midline is a classic sign of bladder
distention. The bladder displaces the uterus, preventing it from contracting effectively. The
nurse should have the client void and reassess the fundus. A full bladder is the most
common cause of uterine atony.
Question 5
A postpartum client who delivered vaginally 6 hours ago has a temperature of 100.4°F
(38°C). Which of the following actions should the nurse take?
,A) Continue to monitor as this is an expected finding
B) Notify the healthcare provider immediately
C) Administer acetaminophen as ordered
D) Encourage oral fluid intake
Correct Answer: A) Continue to monitor as this is an expected finding
Rationale: A temperature of up to 100.4°F (38°C) during the first 24 hours postpartum can
be a normal response to the dehydration and exertion of labor. The nurse should continue
to monitor vital signs. A temperature above 100.4°F after the first 24 hours is more
concerning and should be reported.
Question 6
A nurse is assessing a postpartum client for signs of infection. Which of the following
findings is most concerning?
A) Uterine tenderness
B) Foul-smelling lochia
C) Temperature of 99.8°F
D) Heart rate of 88 bpm
Correct Answer: B) Foul-smelling lochia
Rationale: Foul-smelling lochia is a classic sign of endometritis (infection of the uterine
lining) and requires immediate reporting and treatment. Uterine tenderness is also
concerning but may be expected with afterbirth pains. A temperature of 99.8°F is not yet a
fever (100.4°F is the threshold), and a heart rate of 88 is within normal limits.
Question 7
A nurse is caring for a postpartum client who is 1 hour post-delivery and has saturated
two perineal pads in 15 minutes. What is the priority nursing action?
A) Document the finding
B) Administer oxytocin as ordered
C) Notify the healthcare provider immediately
D) Assess the fundus and massage if boggy
, Correct Answer: D) Assess the fundus and massage if boggy
Rationale: Saturating two perineal pads in 15 minutes indicates excessive bleeding. The
nurse should first assess the fundus. If the fundus is boggy, the nurse should massage it to
stimulate contraction and reduce bleeding. If the fundus is firm, the nurse should look for
other causes such as lacerations. The provider should be notified after immediate
interventions are initiated.
Question 8
A postpartum client who is breastfeeding reports breast pain, redness, and a fever of
101.2°F (38.4°C). The nurse notes a tender, reddened area on the client's right breast.
What is the most likely diagnosis?
A) Breast engorgement
B) Mastitis
C) Plugged milk duct
D) Thrush
Correct Answer: B) Mastitis
Rationale: Mastitis is an infection of the breast tissue characterized by localized breast
pain, redness, warmth, swelling, and fever. It is most common in breastfeeding mothers
and requires antibiotic therapy. Engorgement typically presents with bilateral swelling and
discomfort without fever. A plugged duct presents with a tender lump without systemic
symptoms.
Question 9
A nurse is reinforcing teaching with a client who has mastitis. Which of the following
instructions should the nurse include? (Select all that apply)
A) Apply warm compresses to the affected breast before feeding
B) Breastfeed from the unaffected side first
C) Continue breastfeeding to empty the breast
D) Apply cold compresses after feeding
E) Discontinue breastfeeding until symptoms resolve
