OB Postpartum NCLEX
1. A postpartum nurse is preparing to care for a B) Every 15 minutes during the first hour
woman who has just delivered a healthy new- and then every 30 minutes for the next
born infant. In the immediate postpartum pe- two hours.
riod the nurse plans to take the woman's vital
signs: Rationale: Every 15 minutes during the
A) Every 30 minutes during the first hour and first hour and then every 30 minutes for
then every hour for the next two hours. 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.
2. A postpartum nurse is taking the vital signs D) Increase hydration by encouraging
of a woman who delivered a healthy newborn oral fluids
infant 4 hours ago. The nurse notes that the
mother's temperature is 100.2*F. Which of Rationale: The mother's temperature
the following actions would be most appropri- may be taken every 4 hours while she
ate? is awake. Temperatures up to 100.4 (38
A) Retake the temperature in 15 minutes C) in the first 24 hours after birth are
B) Notify the physician often related to the dehydrating ettects
C) Document the findings of labor. The most appropriate action
D) Increase hydration by encouraging oral flu- is to increase hydration by encouraging
ids oral fluids, which should bring the tem-
perature to a normal reading. Although
the nurse would document the findings,
the most appropriate action would be to
increase the hydration.
3. The nurse is assessing a client who is 6 hours B) Instruct the mother to request help
PP after delivering a full-term healthy infant. when getting out of bed
, OB Postpartum NCLEX
The client complains to the nurse of feelings
of faintness and dizziness. Which of the fol- Rationale: Orthostatic hypotension may
lowing nursing actions would be most appro- be evident during the first 8 hours after
priate? birth. Feelings of faintness or dizziness
A) Obtain hemoglobin and hematocrit levels are signs that should caution the nurse
B) Instruct the mother to request help when to be aware of the client's safety. The
getting out of bed nurse should advise the mother to get
C) Elevate the mother's legs help the first few times the mother gets
D) Inform the nursery room nurse to avoid out of bed. Obtaining an H/H requires a
bringing the newborn infant to the moth- physicians order.
er until the feelings of lightheadedness and
dizziness have subsided
4. A nurse is preparing to perform a fundal as- C) Ask the mother to urinate and empty
sessment on a postpartum client. The initial her bladder
nursing action in performing this assessment
is which of the following? Rationale: Before starting the fundal
A) Ask the client to turn on her side assessment, the nurse should ask the
B) Ask the client to lie flat on her back with the mother to empty her bladder so that
knees and legs flat and straight an accurate assessment can be done.
C) Ask the mother to urinate and empty her When the nurse is performing fundal
bladder assessment, the nurse asks the woman
D) Massage the fundus gently before deter- to lie flat on her back with the knees
mining the level of the fundus. flexed. Massaging the fundus is not ap-
propriate unless the fundus is boggy
and soft, and then it should be mas-
saged gently until firm.
5. The nurse is assessing the lochia on a 1 day B) Indicates the presence of infection
PP patient. The nurse notes that the lochia is
red and has a foul-smelling odor. The nurse Rationale: Lochia, the discharge present
determines that this assessment finding is: after birth, is red for the first 1 to 3 days
, OB Postpartum NCLEX
A) Normal and gradually decreases in amount.
B) Indicates the presence of infection Normal lochia has a fleshy odor. Foul
C) Indicates the need for increasing oral flu- smelling or purulent lochia usually in-
ids dicates infection, and these findings are
D) Indicates the need for increasing ambula- not normal. Encouraging the woman to
tion drink fluids or increase ambulation is
not an accurate nursing intervention
6. When performing a PP assessment on a B) Notify the physician
client, the nurse notes the presence of clots in
the lochia. The nurse examines the clots and Rationale: Normally, one may find a few
notes that they are larger than 1 cm. Which of small clots in the first 1 to 2 days af-
the following nursing actions is most appro- ter birth from pooling of blood in the
priate? vagina. Clots larger than 1 cm are con-
A) Document the findings sidered abnormal. The cause of these
B) Notify the physician clots, such as uterine atony or retained
C) Reassess the client in 2 hours placental fragments, needs to be de-
D) Encourage increased intake of fluids termined and treated to prevent further
blood loss. Although the findings would
be documented, the most appropriate
action is to notify the physician.
7. A nurse in a PP unit is instructing a mother D) Eight peripads per day
regarding lochia and the amount of expect-
ed lochia drainage. The nurse instructs the Rationale: The normal amount of lochia
mother that the normal amount of lochia may may vary with the individual but should
vary but should never exceed the need for: never exceed 4 to 8 peripads per day.
A) One peripad per day The average number of peripads is 6
B) Two peripads per day per day.
C) Three peripads per day
D) Eight peripads per day
8.
1. A postpartum nurse is preparing to care for a B) Every 15 minutes during the first hour
woman who has just delivered a healthy new- and then every 30 minutes for the next
born infant. In the immediate postpartum pe- two hours.
riod the nurse plans to take the woman's vital
signs: Rationale: Every 15 minutes during the
A) Every 30 minutes during the first hour and first hour and then every 30 minutes for
then every hour for the next two hours. 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.
2. A postpartum nurse is taking the vital signs D) Increase hydration by encouraging
of a woman who delivered a healthy newborn oral fluids
infant 4 hours ago. The nurse notes that the
mother's temperature is 100.2*F. Which of Rationale: The mother's temperature
the following actions would be most appropri- may be taken every 4 hours while she
ate? is awake. Temperatures up to 100.4 (38
A) Retake the temperature in 15 minutes C) in the first 24 hours after birth are
B) Notify the physician often related to the dehydrating ettects
C) Document the findings of labor. The most appropriate action
D) Increase hydration by encouraging oral flu- is to increase hydration by encouraging
ids oral fluids, which should bring the tem-
perature to a normal reading. Although
the nurse would document the findings,
the most appropriate action would be to
increase the hydration.
3. The nurse is assessing a client who is 6 hours B) Instruct the mother to request help
PP after delivering a full-term healthy infant. when getting out of bed
, OB Postpartum NCLEX
The client complains to the nurse of feelings
of faintness and dizziness. Which of the fol- Rationale: Orthostatic hypotension may
lowing nursing actions would be most appro- be evident during the first 8 hours after
priate? birth. Feelings of faintness or dizziness
A) Obtain hemoglobin and hematocrit levels are signs that should caution the nurse
B) Instruct the mother to request help when to be aware of the client's safety. The
getting out of bed nurse should advise the mother to get
C) Elevate the mother's legs help the first few times the mother gets
D) Inform the nursery room nurse to avoid out of bed. Obtaining an H/H requires a
bringing the newborn infant to the moth- physicians order.
er until the feelings of lightheadedness and
dizziness have subsided
4. A nurse is preparing to perform a fundal as- C) Ask the mother to urinate and empty
sessment on a postpartum client. The initial her bladder
nursing action in performing this assessment
is which of the following? Rationale: Before starting the fundal
A) Ask the client to turn on her side assessment, the nurse should ask the
B) Ask the client to lie flat on her back with the mother to empty her bladder so that
knees and legs flat and straight an accurate assessment can be done.
C) Ask the mother to urinate and empty her When the nurse is performing fundal
bladder assessment, the nurse asks the woman
D) Massage the fundus gently before deter- to lie flat on her back with the knees
mining the level of the fundus. flexed. Massaging the fundus is not ap-
propriate unless the fundus is boggy
and soft, and then it should be mas-
saged gently until firm.
5. The nurse is assessing the lochia on a 1 day B) Indicates the presence of infection
PP patient. The nurse notes that the lochia is
red and has a foul-smelling odor. The nurse Rationale: Lochia, the discharge present
determines that this assessment finding is: after birth, is red for the first 1 to 3 days
, OB Postpartum NCLEX
A) Normal and gradually decreases in amount.
B) Indicates the presence of infection Normal lochia has a fleshy odor. Foul
C) Indicates the need for increasing oral flu- smelling or purulent lochia usually in-
ids dicates infection, and these findings are
D) Indicates the need for increasing ambula- not normal. Encouraging the woman to
tion drink fluids or increase ambulation is
not an accurate nursing intervention
6. When performing a PP assessment on a B) Notify the physician
client, the nurse notes the presence of clots in
the lochia. The nurse examines the clots and Rationale: Normally, one may find a few
notes that they are larger than 1 cm. Which of small clots in the first 1 to 2 days af-
the following nursing actions is most appro- ter birth from pooling of blood in the
priate? vagina. Clots larger than 1 cm are con-
A) Document the findings sidered abnormal. The cause of these
B) Notify the physician clots, such as uterine atony or retained
C) Reassess the client in 2 hours placental fragments, needs to be de-
D) Encourage increased intake of fluids termined and treated to prevent further
blood loss. Although the findings would
be documented, the most appropriate
action is to notify the physician.
7. A nurse in a PP unit is instructing a mother D) Eight peripads per day
regarding lochia and the amount of expect-
ed lochia drainage. The nurse instructs the Rationale: The normal amount of lochia
mother that the normal amount of lochia may may vary with the individual but should
vary but should never exceed the need for: never exceed 4 to 8 peripads per day.
A) One peripad per day The average number of peripads is 6
B) Two peripads per day per day.
C) Three peripads per day
D) Eight peripads per day
8.
