,NUR 2513 Exam 2 | Maternal-Child Nursing (2026) Actual
Q&A PDF | Rasmussen College
1. A nurse is assessing a postpartum client who is 2 hours post-delivery. The client's
fundus is boggy and displaced to the right side. What is the priority nursing action?
A) Document the findings and continue to monitor
B) Administer a prescribed dose of oxytocin
C) Assist the client to void to empty her bladder
D) Notify the healthcare provider immediately
Correct Answer: Assist the client to void to empty her bladder
Rationale: A boggy fundus displaced to the right is a classic sign of a full bladder
preventing the uterus from contracting effectively. The priority is to have the client
void, which will often allow the fundus to become firm and midline. Oxytocin may be
needed, but the bladder must be emptied first.
2. Why are postpartum women at an increased risk for urinary retention?
A) Decreased bladder sensation due to edema from birth trauma
B) Increased bladder capacity from hormonal changes
C) Excessive fluid intake during the third stage of labor
D) Increased urine output from diuretic medications
Correct Answer: Decreased bladder sensation due to edema from birth trauma
Rationale: Edema and trauma from vaginal delivery can reduce bladder sensation,
making it difficult for the postpartum client to feel the urge to void. This increases
,the risk of urinary retention and subsequent uterine atony. Bladder capacity is not
increased, and diuretics are not routinely given.
3. In differentiating between postpartum depression and baby blues, which
statement should the nurse include in client teaching?
A) Baby blues are the result of hormonal shifts and should resolve by the end of the
sixth postpartum week
B) Baby blues may present in the first few days after birth and resolve prior to the
second postpartum week
C) Postpartum depression may occur on the 5th day but will resolve spontaneously
by the end of the 6th week
D) Postpartum depression is the result of hormonal changes and will not require
intervention
Correct Answer: Baby blues may present in the first few days after birth and resolve
prior to the second postpartum week
Rationale: Baby blues are common, mild mood swings that begin in the first few
days postpartum and typically resolve within two weeks. Postpartum depression is
more severe, persistent beyond two weeks, and requires treatment. Hormonal shifts
contribute to both, but only PPD requires intervention.
4. A postpartum client is prescribed an antibiotic for endometritis. Her breastfed
infant should be observed particularly for which of the following?
A) Irritability and loss of appetite
B) Signs of thrush and easy bruising
C) Decreased sleep levels and increased appetite
D) Jaundice that does not respond to phototherapy
Correct Answer: Signs of thrush and easy bruising
, Rationale: Antibiotics in breastfeeding mothers can alter the infant's normal flora,
increasing the risk for fungal infections such as thrush. They may also affect vitamin
K-producing bacteria, leading to easy bruising. Infants should be monitored for white
patches in the mouth and unusual bruising.
5. What is a priority nursing action for a postpartum client in the fourth stage of
labor?
A) Encourage breastfeeding to promote bonding
B) Assess the fundus and lochia for signs of hemorrhage
C) Provide a light meal to restore energy
D) Monitor blood pressure for signs of preeclampsia
Correct Answer: Assess the fundus and lochia for signs of hemorrhage
Rationale: The fourth stage of labor (first 1-4 hours after delivery) is a critical time
for preventing postpartum hemorrhage. The priority is to assess the fundus for
firmness and position and to monitor lochia for amount and color. Breastfeeding and
nutrition are important but secondary to hemorrhage prevention.
6. The nurse is assessing a postpartum client's lochia. Which finding is within normal
limits for the first 3-4 days postpartum?
A) Lochia serosa with a pinkish-brown color
B) Lochia rubra with a bright red color
C) Lochia alba with a yellowish-white color
D) Lochia with large clots greater than 1 cm
Correct Answer: Lochia rubra with a bright red color
Q&A PDF | Rasmussen College
1. A nurse is assessing a postpartum client who is 2 hours post-delivery. The client's
fundus is boggy and displaced to the right side. What is the priority nursing action?
A) Document the findings and continue to monitor
B) Administer a prescribed dose of oxytocin
C) Assist the client to void to empty her bladder
D) Notify the healthcare provider immediately
Correct Answer: Assist the client to void to empty her bladder
Rationale: A boggy fundus displaced to the right is a classic sign of a full bladder
preventing the uterus from contracting effectively. The priority is to have the client
void, which will often allow the fundus to become firm and midline. Oxytocin may be
needed, but the bladder must be emptied first.
2. Why are postpartum women at an increased risk for urinary retention?
A) Decreased bladder sensation due to edema from birth trauma
B) Increased bladder capacity from hormonal changes
C) Excessive fluid intake during the third stage of labor
D) Increased urine output from diuretic medications
Correct Answer: Decreased bladder sensation due to edema from birth trauma
Rationale: Edema and trauma from vaginal delivery can reduce bladder sensation,
making it difficult for the postpartum client to feel the urge to void. This increases
,the risk of urinary retention and subsequent uterine atony. Bladder capacity is not
increased, and diuretics are not routinely given.
3. In differentiating between postpartum depression and baby blues, which
statement should the nurse include in client teaching?
A) Baby blues are the result of hormonal shifts and should resolve by the end of the
sixth postpartum week
B) Baby blues may present in the first few days after birth and resolve prior to the
second postpartum week
C) Postpartum depression may occur on the 5th day but will resolve spontaneously
by the end of the 6th week
D) Postpartum depression is the result of hormonal changes and will not require
intervention
Correct Answer: Baby blues may present in the first few days after birth and resolve
prior to the second postpartum week
Rationale: Baby blues are common, mild mood swings that begin in the first few
days postpartum and typically resolve within two weeks. Postpartum depression is
more severe, persistent beyond two weeks, and requires treatment. Hormonal shifts
contribute to both, but only PPD requires intervention.
4. A postpartum client is prescribed an antibiotic for endometritis. Her breastfed
infant should be observed particularly for which of the following?
A) Irritability and loss of appetite
B) Signs of thrush and easy bruising
C) Decreased sleep levels and increased appetite
D) Jaundice that does not respond to phototherapy
Correct Answer: Signs of thrush and easy bruising
, Rationale: Antibiotics in breastfeeding mothers can alter the infant's normal flora,
increasing the risk for fungal infections such as thrush. They may also affect vitamin
K-producing bacteria, leading to easy bruising. Infants should be monitored for white
patches in the mouth and unusual bruising.
5. What is a priority nursing action for a postpartum client in the fourth stage of
labor?
A) Encourage breastfeeding to promote bonding
B) Assess the fundus and lochia for signs of hemorrhage
C) Provide a light meal to restore energy
D) Monitor blood pressure for signs of preeclampsia
Correct Answer: Assess the fundus and lochia for signs of hemorrhage
Rationale: The fourth stage of labor (first 1-4 hours after delivery) is a critical time
for preventing postpartum hemorrhage. The priority is to assess the fundus for
firmness and position and to monitor lochia for amount and color. Breastfeeding and
nutrition are important but secondary to hemorrhage prevention.
6. The nurse is assessing a postpartum client's lochia. Which finding is within normal
limits for the first 3-4 days postpartum?
A) Lochia serosa with a pinkish-brown color
B) Lochia rubra with a bright red color
C) Lochia alba with a yellowish-white color
D) Lochia with large clots greater than 1 cm
Correct Answer: Lochia rubra with a bright red color
