NUR 254 EXAM 2 – COMPREHENSIVE TEST
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350+ Updated Actual Exam Questions with Verified Correct
Answers and Rationales
Section 1: Postpartum Assessment and Complications (Questions
1–50)
Question 1
The nurse is teaching a client with Type 1 diabetes who just delivered a healthy baby. Which
information should the nurse include in the client's teaching?
A) Change to oral hypoglycemic medications that will control sugar levels better than insulin
B) Urine should be checked for ketones every time the client voids
C) Due to hormonal changes after delivery, the need for insulin may decrease
D) Feed the baby formula since insulin received through breastfeeding may cause low blood sugar
Answer
Answer: C
Rationale
Postpartum hormonal shifts can reduce insulin resistance, leading to a decreased requirement for
exogenous insulin. Clients should be educated about this change to avoid hypoglycemia and maintain
appropriate glycemic control. Insulin requirements typically drop significantly after delivery of the
placenta.
Question 2
The nurse is caring for the following clients in the postpartum unit. Which client should the
nurse see first?
A) Multipara mother who has saturated 2 perineal pads in one hour
B) Primipara mother who delivered 3 hours ago and is having difficulty getting the baby to latch on to
the breast
C) Primipara mother requesting help with repositioning her baby to decrease incisional pain from a
cesarean delivery
D) Multipara mother who is requesting pain medication for afterbirth cramps
,Answer
Answer: A
Rationale
Saturating two perineal pads in one hour is a sign of postpartum hemorrhage and is the priority. This
client requires immediate assessment and intervention. The other clients have needs that, while
important, are not immediately life-threatening.
Question 3
The nurse is assessing a client who is 24 hours postpartum. Which finding is most important
for the nurse to follow up?
A) Voided 2125 mL of clear yellow urine in the last 24 hours
B) Fundus is slightly firm
C) White blood cell count of 8.5 mm
D) Perineal pad saturated
Answer
Answer: D
Rationale
Saturated perineal pads may indicate hemorrhage and require immediate follow-up. A WBC of 8.5 is
within normal limits. While 2125 mL is a large urine output, it is not as immediately concerning as a
saturated pad. The fundus should be firm.
Question 4
The nurse notes that a postpartum client's fundus is boggy (soft) and displaced to the right,
above the umbilicus. What is the nurse's priority action?
A) Document the finding and reassess in 4 hours
B) Massage the fundus and assist the client to void
C) Administer pain medication as prescribed
D) Increase the client's oral fluid intake
Answer
Answer: B
2
,Rationale
A boggy, displaced fundus indicates uterine atony and a full bladder. The nurse should massage the
fundus to stimulate contraction and assist the client to void to empty the bladder, which will allow the
uterus to contract effectively.
Question 5
Which uterine assessment finding is expected in a client 12 hours postpartum?
A) Boggy uterus deviated to the right
B) Firm uterus at the level of the umbilicus
C) Uterus 3 cm above the umbilicus
D) Uterus deviated to the left
Answer
Answer: B
Rationale
Within the first 12 hours postpartum, the fundus should be firm and located at the level of the
umbilicus. A boggy or deviated uterus indicates complications such as uterine atony or full bladder.
Question 6
The nurse is assessing a postpartum client's lochia on the second day postpartum. Which
finding is expected?
A) Lochia alba, scant amount
B) Lochia rubra, moderate amount
C) Lochia serosa, heavy amount
D) Lochia rubra, scant amount
Answer
Answer: B
Rationale
Lochia rubra is expected during the first 3-4 days postpartum. On day 2, a moderate amount of lochia
rubra is a normal finding. Lochia serosa follows after 4 days, and lochia alba appears after
3
, approximately 10 days.
Question 7
A postpartum client is prescribed methylergonovine (Methergine). Which assessment finding
requires the nurse to hold the medication and notify the provider?
A) Blood pressure of 150/95 mm Hg
B) Heart rate of 88 beats per minute
C) Respiratory rate of 18 breaths per minute
D) Temperature of 99.2°F
Answer
Answer: A
Rationale
Methylergonovine is a uterotonic agent that can cause hypertension. It is contraindicated in clients with
hypertension, preeclampsia, or cardiac disease. The nurse should hold the medication and notify the
provider.
Question 8
A postpartum client is assessed one hour after a vaginal birth. The nurse finds the fundus
boggy at the level of the umbilicus and lochia rubra heavy. What is the priority nursing
intervention?
A) Document the findings and reassess in 30 minutes
B) Massage the fundus until firm and administer prescribed oxytocin
C) Increase the IV fluid rate to 150 mL/hour
D) Place the client in a supine position and apply ice to the perineum
Answer
Answer: B
Rationale
A boggy fundus with heavy lochia indicates uterine atony and risk for hemorrhage. The priority is to
massage the fundus until firm and administer uterotonic medications such as oxytocin to promote
uterine contraction.
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BANK
350+ Updated Actual Exam Questions with Verified Correct
Answers and Rationales
Section 1: Postpartum Assessment and Complications (Questions
1–50)
Question 1
The nurse is teaching a client with Type 1 diabetes who just delivered a healthy baby. Which
information should the nurse include in the client's teaching?
A) Change to oral hypoglycemic medications that will control sugar levels better than insulin
B) Urine should be checked for ketones every time the client voids
C) Due to hormonal changes after delivery, the need for insulin may decrease
D) Feed the baby formula since insulin received through breastfeeding may cause low blood sugar
Answer
Answer: C
Rationale
Postpartum hormonal shifts can reduce insulin resistance, leading to a decreased requirement for
exogenous insulin. Clients should be educated about this change to avoid hypoglycemia and maintain
appropriate glycemic control. Insulin requirements typically drop significantly after delivery of the
placenta.
Question 2
The nurse is caring for the following clients in the postpartum unit. Which client should the
nurse see first?
A) Multipara mother who has saturated 2 perineal pads in one hour
B) Primipara mother who delivered 3 hours ago and is having difficulty getting the baby to latch on to
the breast
C) Primipara mother requesting help with repositioning her baby to decrease incisional pain from a
cesarean delivery
D) Multipara mother who is requesting pain medication for afterbirth cramps
,Answer
Answer: A
Rationale
Saturating two perineal pads in one hour is a sign of postpartum hemorrhage and is the priority. This
client requires immediate assessment and intervention. The other clients have needs that, while
important, are not immediately life-threatening.
Question 3
The nurse is assessing a client who is 24 hours postpartum. Which finding is most important
for the nurse to follow up?
A) Voided 2125 mL of clear yellow urine in the last 24 hours
B) Fundus is slightly firm
C) White blood cell count of 8.5 mm
D) Perineal pad saturated
Answer
Answer: D
Rationale
Saturated perineal pads may indicate hemorrhage and require immediate follow-up. A WBC of 8.5 is
within normal limits. While 2125 mL is a large urine output, it is not as immediately concerning as a
saturated pad. The fundus should be firm.
Question 4
The nurse notes that a postpartum client's fundus is boggy (soft) and displaced to the right,
above the umbilicus. What is the nurse's priority action?
A) Document the finding and reassess in 4 hours
B) Massage the fundus and assist the client to void
C) Administer pain medication as prescribed
D) Increase the client's oral fluid intake
Answer
Answer: B
2
,Rationale
A boggy, displaced fundus indicates uterine atony and a full bladder. The nurse should massage the
fundus to stimulate contraction and assist the client to void to empty the bladder, which will allow the
uterus to contract effectively.
Question 5
Which uterine assessment finding is expected in a client 12 hours postpartum?
A) Boggy uterus deviated to the right
B) Firm uterus at the level of the umbilicus
C) Uterus 3 cm above the umbilicus
D) Uterus deviated to the left
Answer
Answer: B
Rationale
Within the first 12 hours postpartum, the fundus should be firm and located at the level of the
umbilicus. A boggy or deviated uterus indicates complications such as uterine atony or full bladder.
Question 6
The nurse is assessing a postpartum client's lochia on the second day postpartum. Which
finding is expected?
A) Lochia alba, scant amount
B) Lochia rubra, moderate amount
C) Lochia serosa, heavy amount
D) Lochia rubra, scant amount
Answer
Answer: B
Rationale
Lochia rubra is expected during the first 3-4 days postpartum. On day 2, a moderate amount of lochia
rubra is a normal finding. Lochia serosa follows after 4 days, and lochia alba appears after
3
, approximately 10 days.
Question 7
A postpartum client is prescribed methylergonovine (Methergine). Which assessment finding
requires the nurse to hold the medication and notify the provider?
A) Blood pressure of 150/95 mm Hg
B) Heart rate of 88 beats per minute
C) Respiratory rate of 18 breaths per minute
D) Temperature of 99.2°F
Answer
Answer: A
Rationale
Methylergonovine is a uterotonic agent that can cause hypertension. It is contraindicated in clients with
hypertension, preeclampsia, or cardiac disease. The nurse should hold the medication and notify the
provider.
Question 8
A postpartum client is assessed one hour after a vaginal birth. The nurse finds the fundus
boggy at the level of the umbilicus and lochia rubra heavy. What is the priority nursing
intervention?
A) Document the findings and reassess in 30 minutes
B) Massage the fundus until firm and administer prescribed oxytocin
C) Increase the IV fluid rate to 150 mL/hour
D) Place the client in a supine position and apply ice to the perineum
Answer
Answer: B
Rationale
A boggy fundus with heavy lochia indicates uterine atony and risk for hemorrhage. The priority is to
massage the fundus until firm and administer uterotonic medications such as oxytocin to promote
uterine contraction.
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