1. A nurse is assessing a postpartum client who is 12 hours after a vaginal
delivery. The nurse notes that the client’s fundus is 1 cm above the umbilicus and
displaced to the right. Which of the following actions should the nurse take first?
A. Notify the provider.
B. Assist the client to the bathroom to void.
C. Massage the fundus.
D. Document the findings.
Answer: B. Assist the client to the bathroom to void.
Rationale: A displaced fundus is often due to bladder distention, and assisting the client to void
should be the first action. If the fundus remains displaced after voiding, the nurse can then
massage the fundus.
2. A postpartum client is concerned about her lochia being bright red and heavy.
Which of the following is an appropriate response by the nurse?
A. "This is abnormal, and you should notify your provider immediately."
B. "Bright red and heavy lochia is expected for the first 3-4 days after delivery."
C. "It is common to have dark brown discharge at this stage."
D. "You should not have bright red lochia at all after the first 12 hours."
Answer: B. "Bright red and heavy lochia is expected for the first 3-4 days after delivery."
Rationale: Lochia typically progresses from bright red (rubra) to pink (serosa) to white (alba)
over several days after delivery. Bright red lochia is expected in the first 3-4 days postpartum.
3. A client who gave birth vaginally 24 hours ago is asking about her postpartum
bleeding. She states she has soaked one pad in 2 hours. What is the nurse’s best
response?
A. "This is excessive bleeding, and you need to be seen by your provider."
B. "This is normal as long as the bleeding is bright red."
C. "You should not have saturated a pad so quickly, but I will check you over."
D. "This amount of bleeding is within normal limits for the first 24 hours."
Answer: C. "You should not have saturated a pad so quickly, but I will check you over."
,Rationale: While some bleeding is expected after delivery, saturating a pad in less than 1 hour is
concerning. The nurse should assess the client for excessive bleeding or other complications,
such as uterine atony or retained placental fragments.
4. A nurse is teaching a postpartum client about breast care. The nurse should
include which of the following as an appropriate technique for relieving
engorgement?
A. Apply ice packs to the breasts.
B. Wear a tight-fitting bra.
C. Use warm compresses prior to breastfeeding.
D. Discontinue breastfeeding if engorged.
Answer: C. Use warm compresses prior to breastfeeding.
Rationale: Warm compresses help to promote milk flow and relieve engorgement. Cold packs
can reduce swelling but should not be used before breastfeeding, as they may hinder milk flow.
5. A nurse is preparing a client for a cesarean section. Which of the following
interventions should the nurse perform to reduce the risk of infection?
A. Instruct the client to cough and deep breathe during surgery.
B. Administer antibiotics as prescribed.
C. Apply a heating pad to the incision site.
D. Place the client in a supine position with legs elevated.
Answer: B. Administer antibiotics as prescribed.
Rationale: Antibiotic administration before cesarean delivery helps reduce the risk of infection.
Proper positioning and other measures may be indicated, but antibiotic prophylaxis is key in
reducing infection risk.
6. A nurse is caring for a newborn who has a cephalohematoma. Which of the
following should the nurse include in the plan of care?
A. Place the newborn in a side-lying position.
B. Apply ice to the area for the first 24 hours.
C. Avoid monitoring the newborn's head circumference.
D. Document the cephalohematoma and reassess the newborn regularly.
, Answer: D. Document the cephalohematoma and reassess the newborn regularly.
Rationale: A cephalohematoma typically resolves on its own without treatment. The nurse
should monitor for any complications, such as jaundice, and document the finding. Ice
application is not typically used.
7. A nurse is assessing a newborn for signs of jaundice. Which of the following is
the most reliable indication of jaundice in the newborn?
A. Yellow sclera
B. Yellow palms of the hands
C. Yellow soles of the feet
D. Yellow mucous membranes
Answer: A. Yellow sclera
Rationale: Jaundice is most reliably observed in the sclera of the eyes. The yellowing of the skin
and mucous membranes are also signs, but scleral yellowing is a more consistent indicator.
8. A postpartum client is experiencing severe abdominal cramping, particularly
while breastfeeding. Which of the following interventions should the nurse
recommend?
A. Increase fluid intake.
B. Administer a mild analgesic.
C. Perform perineal exercises.
D. Encourage deep breathing and relaxation techniques.
Answer: B. Administer a mild analgesic.
Rationale: Postpartum cramping, or uterine afterpains, is common, especially during
breastfeeding due to oxytocin release. Mild analgesics such as ibuprofen can help alleviate
discomfort.
9. A nurse is assessing a postpartum client 2 hours after delivery. The client
reports a headache and blurred vision. The nurse notes swelling of the hands and
face. What is the nurse’s priority action?
delivery. The nurse notes that the client’s fundus is 1 cm above the umbilicus and
displaced to the right. Which of the following actions should the nurse take first?
A. Notify the provider.
B. Assist the client to the bathroom to void.
C. Massage the fundus.
D. Document the findings.
Answer: B. Assist the client to the bathroom to void.
Rationale: A displaced fundus is often due to bladder distention, and assisting the client to void
should be the first action. If the fundus remains displaced after voiding, the nurse can then
massage the fundus.
2. A postpartum client is concerned about her lochia being bright red and heavy.
Which of the following is an appropriate response by the nurse?
A. "This is abnormal, and you should notify your provider immediately."
B. "Bright red and heavy lochia is expected for the first 3-4 days after delivery."
C. "It is common to have dark brown discharge at this stage."
D. "You should not have bright red lochia at all after the first 12 hours."
Answer: B. "Bright red and heavy lochia is expected for the first 3-4 days after delivery."
Rationale: Lochia typically progresses from bright red (rubra) to pink (serosa) to white (alba)
over several days after delivery. Bright red lochia is expected in the first 3-4 days postpartum.
3. A client who gave birth vaginally 24 hours ago is asking about her postpartum
bleeding. She states she has soaked one pad in 2 hours. What is the nurse’s best
response?
A. "This is excessive bleeding, and you need to be seen by your provider."
B. "This is normal as long as the bleeding is bright red."
C. "You should not have saturated a pad so quickly, but I will check you over."
D. "This amount of bleeding is within normal limits for the first 24 hours."
Answer: C. "You should not have saturated a pad so quickly, but I will check you over."
,Rationale: While some bleeding is expected after delivery, saturating a pad in less than 1 hour is
concerning. The nurse should assess the client for excessive bleeding or other complications,
such as uterine atony or retained placental fragments.
4. A nurse is teaching a postpartum client about breast care. The nurse should
include which of the following as an appropriate technique for relieving
engorgement?
A. Apply ice packs to the breasts.
B. Wear a tight-fitting bra.
C. Use warm compresses prior to breastfeeding.
D. Discontinue breastfeeding if engorged.
Answer: C. Use warm compresses prior to breastfeeding.
Rationale: Warm compresses help to promote milk flow and relieve engorgement. Cold packs
can reduce swelling but should not be used before breastfeeding, as they may hinder milk flow.
5. A nurse is preparing a client for a cesarean section. Which of the following
interventions should the nurse perform to reduce the risk of infection?
A. Instruct the client to cough and deep breathe during surgery.
B. Administer antibiotics as prescribed.
C. Apply a heating pad to the incision site.
D. Place the client in a supine position with legs elevated.
Answer: B. Administer antibiotics as prescribed.
Rationale: Antibiotic administration before cesarean delivery helps reduce the risk of infection.
Proper positioning and other measures may be indicated, but antibiotic prophylaxis is key in
reducing infection risk.
6. A nurse is caring for a newborn who has a cephalohematoma. Which of the
following should the nurse include in the plan of care?
A. Place the newborn in a side-lying position.
B. Apply ice to the area for the first 24 hours.
C. Avoid monitoring the newborn's head circumference.
D. Document the cephalohematoma and reassess the newborn regularly.
, Answer: D. Document the cephalohematoma and reassess the newborn regularly.
Rationale: A cephalohematoma typically resolves on its own without treatment. The nurse
should monitor for any complications, such as jaundice, and document the finding. Ice
application is not typically used.
7. A nurse is assessing a newborn for signs of jaundice. Which of the following is
the most reliable indication of jaundice in the newborn?
A. Yellow sclera
B. Yellow palms of the hands
C. Yellow soles of the feet
D. Yellow mucous membranes
Answer: A. Yellow sclera
Rationale: Jaundice is most reliably observed in the sclera of the eyes. The yellowing of the skin
and mucous membranes are also signs, but scleral yellowing is a more consistent indicator.
8. A postpartum client is experiencing severe abdominal cramping, particularly
while breastfeeding. Which of the following interventions should the nurse
recommend?
A. Increase fluid intake.
B. Administer a mild analgesic.
C. Perform perineal exercises.
D. Encourage deep breathing and relaxation techniques.
Answer: B. Administer a mild analgesic.
Rationale: Postpartum cramping, or uterine afterpains, is common, especially during
breastfeeding due to oxytocin release. Mild analgesics such as ibuprofen can help alleviate
discomfort.
9. A nurse is assessing a postpartum client 2 hours after delivery. The client
reports a headache and blurred vision. The nurse notes swelling of the hands and
face. What is the nurse’s priority action?
