OB Postpartum NCLEX Questions and Answers 2024 A postpartum nurse is preparing to care for a woman who has just delivered a healthy newborn infant. In the immediate postpartum period the nurse plans to take the woman's vital signs:
A) Every 30 minutes during the first hour and then every hour for the next two hours.
B) Every 15 minutes during the first hour and then every 30 minutes for the next two hours.
C) Every hour for the first 2 hours and then every 4 hours
D) Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours. - ANSWER-B) Every 15 minutes during the first hour and then every 30 minutes for the next two hours.
Rationale: Every 15 minutes during the first hour and then every 30 minutes for the next
two hours.
A postpartum nurse is taking the vital signs of a woman who delivered a healthy newborn infant 4 hours ago. The nurse notes that the mother's temperature is 100.2*F. Which of the following actions would be most appropriate?
A) Retake the temperature in 15 minutes
B) Notify the physician
C) Document the findings
D) Increase hydration by encouraging oral fluids - ANSWER-D) Increase hydration by encouraging oral fluids
Rationale: The mother's temperature may be taken every 4 hours while she is awake. Temperatures up to 100.4 (38 C) in the first 24 hours after birth are often related to the dehydrating effects of labor. The most appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse would document the findings, the most appropriate action would be to increase the hydration.
The nurse is assessing a client who is 6 hours PP after delivering a full-term healthy infant. The client complains to the nurse of feelings of faintness and dizziness. Which of the following nursing actions would be most appropriate?
A) Obtain hemoglobin and hematocrit levels
B) Instruct the mother to request help when getting out of bed
C) Elevate the mother's legs
D) Inform the nursery room nurse to avoid bringing the newborn infant to the mother until the feelings of lightheadedness and dizziness have subsided - ANSWER-B) Instruct the mother to request help when getting out of bed Rationale: Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that should caution the nurse to be aware of
the client's safety. The nurse should advise the mother to get help the first few times the
mother gets out of bed. Obtaining an H/H requires a physicians order.
A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing action in performing this assessment is which of the following?
A) Ask the client to turn on her side
B) Ask the client to lie flat on her back with the knees and legs flat and straight
C) Ask the mother to urinate and empty her bladder
D) Massage the fundus gently before determining the level of the fundus. - ANSWER-C)
Ask the mother to urinate and empty her bladder
Rationale: Before starting the fundal assessment, the nurse should ask the mother to empty her bladder so that an accurate assessment can be done. When the nurse is performing fundal assessment, the nurse asks the woman to lie flat on her back with the
knees flexed. Massaging the fundus is not appropriate unless the fundus is boggy and soft, and then it should be massaged gently until firm.
The nurse is assessing the lochia on a 1 day PP patient. The nurse notes that the lochia
is red and has a foul-smelling odor. The nurse determines that this assessment finding is:
A) Normal
B) Indicates the presence of infection
C) Indicates the need for increasing oral fluids
D) Indicates the need for increasing ambulation - ANSWER-B) Indicates the presence of infection
Rationale: Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor. Foul smelling or purulent lochia usually indicates infection, and these findings are not normal. Encouraging the woman to drink fluids or increase ambulation is not an accurate nursing intervention
When performing a PP assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which of the following nursing actions is most appropriate?
A) Document the findings
B) Notify the physician
C) Reassess the client in 2 hours
D) Encourage increased intake of fluids - ANSWER-B) Notify the physician
Rationale: Normally, one may find a few small clots in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the most appropriate action is to notify the physician.
A nurse in a PP unit is instructing a mother regarding lochia and the amount of expected
lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed the need for:
A) One peripad per day
B) Two peripads per day
C) Three peripads per day
D) Eight peripads per day - ANSWER-D) Eight peripads per day
Rationale: The normal amount of lochia may vary with the individual but should never exceed 4 to 8 peripads per day. The average number of peripads is 6 per day.
A PP nurse is providing instructions to a woman after delivery of a healthy newborn infant. The nurse instructs the mother that she should expect normal bowel elimination to return:
A) One the day of the delivery
B) 3 days PP
C) 7 days PP
D) within 2 weeks PP - ANSWER-B) 3 days PP
Rationale: After birth, the nurse should auscultate the woman's abdomen in all four quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days PP. Surgery, anesthesia, and the use of narcotics and pain control agents also contribute to the longer period of altered bowel function
Select all of the physiological maternal changes that occur during the PP period. (Select
all that apply)
A) Cervical involution occurs
B) Vaginal distention decreases slowly
C) Fundus begins to descend into the pelvis after 24 hours
D) Cardiac output decreases with resultant tachycardia in the first 24 hours
E) Digestive processes slow immediately - ANSWER-A) Cervical involution occurs
C) Fundus begins to descend into the pelvis after 24 hours
Rationale: After 1 week the muscle begins to regenerate and the cervix feels firm and the external os is the width of a pencil. Although the vaginal mucosa heals and vaginal distention decreases, it takes the entire PP period for complete involution to occur and muscle tone is never restored to the pregravid state. The fundus begins to descent into the pelvic cavity after 24 hours, a process known as involution. Despite blood loss that occurs during delivery of the baby, a transient increase in cardiac output occurs. The increase in cardiac output, which persists about 48 hours after childbirth, is probably caused by an increase in stroke volume because Bradycardia is often noted during the PP period. Soon after childbirth, digestion begins to begin to be active and the new mother is usually hungry because of the energy expended during labor.
A) Every 30 minutes during the first hour and then every hour for the next two hours.
B) Every 15 minutes during the first hour and then every 30 minutes for the next two hours.
C) Every hour for the first 2 hours and then every 4 hours
D) Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours. - ANSWER-B) Every 15 minutes during the first hour and then every 30 minutes for the next two hours.
Rationale: Every 15 minutes during the first hour and then every 30 minutes for the next
two hours.
A postpartum nurse is taking the vital signs of a woman who delivered a healthy newborn infant 4 hours ago. The nurse notes that the mother's temperature is 100.2*F. Which of the following actions would be most appropriate?
A) Retake the temperature in 15 minutes
B) Notify the physician
C) Document the findings
D) Increase hydration by encouraging oral fluids - ANSWER-D) Increase hydration by encouraging oral fluids
Rationale: The mother's temperature may be taken every 4 hours while she is awake. Temperatures up to 100.4 (38 C) in the first 24 hours after birth are often related to the dehydrating effects of labor. The most appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse would document the findings, the most appropriate action would be to increase the hydration.
The nurse is assessing a client who is 6 hours PP after delivering a full-term healthy infant. The client complains to the nurse of feelings of faintness and dizziness. Which of the following nursing actions would be most appropriate?
A) Obtain hemoglobin and hematocrit levels
B) Instruct the mother to request help when getting out of bed
C) Elevate the mother's legs
D) Inform the nursery room nurse to avoid bringing the newborn infant to the mother until the feelings of lightheadedness and dizziness have subsided - ANSWER-B) Instruct the mother to request help when getting out of bed Rationale: Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that should caution the nurse to be aware of
the client's safety. The nurse should advise the mother to get help the first few times the
mother gets out of bed. Obtaining an H/H requires a physicians order.
A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing action in performing this assessment is which of the following?
A) Ask the client to turn on her side
B) Ask the client to lie flat on her back with the knees and legs flat and straight
C) Ask the mother to urinate and empty her bladder
D) Massage the fundus gently before determining the level of the fundus. - ANSWER-C)
Ask the mother to urinate and empty her bladder
Rationale: Before starting the fundal assessment, the nurse should ask the mother to empty her bladder so that an accurate assessment can be done. When the nurse is performing fundal assessment, the nurse asks the woman to lie flat on her back with the
knees flexed. Massaging the fundus is not appropriate unless the fundus is boggy and soft, and then it should be massaged gently until firm.
The nurse is assessing the lochia on a 1 day PP patient. The nurse notes that the lochia
is red and has a foul-smelling odor. The nurse determines that this assessment finding is:
A) Normal
B) Indicates the presence of infection
C) Indicates the need for increasing oral fluids
D) Indicates the need for increasing ambulation - ANSWER-B) Indicates the presence of infection
Rationale: Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor. Foul smelling or purulent lochia usually indicates infection, and these findings are not normal. Encouraging the woman to drink fluids or increase ambulation is not an accurate nursing intervention
When performing a PP assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which of the following nursing actions is most appropriate?
A) Document the findings
B) Notify the physician
C) Reassess the client in 2 hours
D) Encourage increased intake of fluids - ANSWER-B) Notify the physician
Rationale: Normally, one may find a few small clots in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the most appropriate action is to notify the physician.
A nurse in a PP unit is instructing a mother regarding lochia and the amount of expected
lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed the need for:
A) One peripad per day
B) Two peripads per day
C) Three peripads per day
D) Eight peripads per day - ANSWER-D) Eight peripads per day
Rationale: The normal amount of lochia may vary with the individual but should never exceed 4 to 8 peripads per day. The average number of peripads is 6 per day.
A PP nurse is providing instructions to a woman after delivery of a healthy newborn infant. The nurse instructs the mother that she should expect normal bowel elimination to return:
A) One the day of the delivery
B) 3 days PP
C) 7 days PP
D) within 2 weeks PP - ANSWER-B) 3 days PP
Rationale: After birth, the nurse should auscultate the woman's abdomen in all four quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days PP. Surgery, anesthesia, and the use of narcotics and pain control agents also contribute to the longer period of altered bowel function
Select all of the physiological maternal changes that occur during the PP period. (Select
all that apply)
A) Cervical involution occurs
B) Vaginal distention decreases slowly
C) Fundus begins to descend into the pelvis after 24 hours
D) Cardiac output decreases with resultant tachycardia in the first 24 hours
E) Digestive processes slow immediately - ANSWER-A) Cervical involution occurs
C) Fundus begins to descend into the pelvis after 24 hours
Rationale: After 1 week the muscle begins to regenerate and the cervix feels firm and the external os is the width of a pencil. Although the vaginal mucosa heals and vaginal distention decreases, it takes the entire PP period for complete involution to occur and muscle tone is never restored to the pregravid state. The fundus begins to descent into the pelvic cavity after 24 hours, a process known as involution. Despite blood loss that occurs during delivery of the baby, a transient increase in cardiac output occurs. The increase in cardiac output, which persists about 48 hours after childbirth, is probably caused by an increase in stroke volume because Bradycardia is often noted during the PP period. Soon after childbirth, digestion begins to begin to be active and the new mother is usually hungry because of the energy expended during labor.
