NUR 254 Exam 2 Review Questions & Answers
Galen College of Nursing | Updated 2025-2026
Complete 300-Question Bank with Detailed Rationales
Section 1: Postpartum Assessment & BUBBLE-HE Framework
(Questions 1-40)
Question 1: The nurse is performing a postpartum assessment on a client who delivered vaginally 12
hours ago. The fundus is located 1 cm below the umbilicus, midline, and firm. Lochia is moderate
rubra. What is the appropriate nursing action?
A) Notify the healthcare provider immediately
B) Massage the fundus vigorously
C) Document the findings as normal
D) Prepare for ultrasound examination
Answer: C) Document the findings as normal
Rationale: Normal uterine involution occurs at a rate of 1-2 cm per day. At 12 hours postpartum, the
fundus should be at or slightly below the umbilicus. A firm, midline fundus with moderate rubra lochia
indicates adequate uterine contraction and normal involution. Vigorous massage is not indicated for a
firm fundus.
Question 2: A client who is 6 hours postpartum has a boggy uterus that is displaced to the right. What
is the nurse's priority action?
A) Administer oxytocin as ordered
B) Assist the client to void
C) Increase the IV fluid rate
D) Notify the healthcare provider
Answer: B) Assist the client to void
Rationale: A displaced uterus (typically to the right) is a classic sign of a full bladder. A distended
bladder lifts the uterus and prevents it from contracting effectively, leading to uterine atony and
increased risk of postpartum hemorrhage. The priority is to help the client void, then reassess the
fundus. Oxytocin may be needed after bladder emptying if the fundus remains boggy.
,Question 3: A postpartum client has saturated two perineal pads within one hour. The fundus is firm
and midline. What should the nurse suspect?
A) Normal postpartum bleeding
B) Uterine atony
C) Lacerations of the reproductive tract
D) Retained placental fragments
Answer: C) Lacerations of the reproductive tract
Rationale: When the fundus is firm but bleeding is excessive, the source is likely lacerations of the
cervix or vagina rather than uterine atony. A saturated pad within one hour is classified as heavy
bleeding requiring immediate investigation. Uterine atony presents with a boggy fundus, not a firm
one. Retained fragments typically cause late postpartum bleeding.
Question 4: The nurse is teaching a postpartum client about lochia progression. Which statement
indicates correct understanding?
A) "Lochia rubra should change to alba within 3 days."
B) "Lochia serosa is pinkish-brown and occurs around days 4-10."
C) "Lochia alba is bright red and lasts for 2 weeks."
D) "Lochia should stop completely by day 7."
Answer: B) Lochia serosa is pinkish-brown and occurs around days 4-10
Rationale: Lochia progresses through three stages: Rubra (bright red, days 1-3), Serosa (pinkish-
brown, days 4-10), and Alba (yellowish-white, days 10-14+). Lochia may continue for 3-6 weeks total.
Teaching patients this progression is essential for recognizing abnormal bleeding patterns.
Question 5: In the BUBBLE-HE postpartum assessment framework, which component includes
assessment of the perineum using REEDA?
A) Breasts
B) Uterus
C) Bladder
D) Episiotomy
Answer: D) Episiotomy
Rationale: BUBBLE-HE stands
for Breasts, U terus, B ladder, Bowels, L ochia, E pisiotomy, H emorrhoids, E motional status. The "E" for
Episiotomy includes perineal assessment using
REEDA: Redness, E dema, E cchymosis, D ischarge, A pproximation.
,Question 6: What is the REEDA assessment used for in postpartum care?
A) Assessing lochia color and amount
B) Evaluating episiotomy or perineal healing
C) Monitoring uterine involution
D) Assessing breast engorgement
Answer: B) Evaluating episiotomy or perineal healing
Rationale: REEDA is a systematic assessment tool for perineal healing following episiotomy or
laceration repair. It evaluates Redness, Edema, Ecchymosis, Discharge, and Approximation of wound
edges. Any abnormality should be reported to the healthcare provider.
Question 7: A postpartum client reports perineal pain rated 7/10. The nurse notes ecchymosis and
edema along the episiotomy site. Which intervention is most appropriate for the first 24 hours?
A) Apply warm sitz baths
B) Apply ice packs for 10-15 minutes alternating on and off
C) Administer oral opioids
D) Apply topical lidocaine gel
Answer: B) Apply ice packs for 10-15 minutes alternating on and off
Rationale: During the first 24 hours postpartum, ice packs are the standard intervention for perineal
pain and edema. Ice causes vasoconstriction, reducing swelling and providing local anesthesia. After
24 hours, warm sitz baths promote circulation and healing. Topical anesthetics may be used but
require assessment for intact skin.
Question 8: A non-breastfeeding mother asks how to suppress her milk production. Which
recommendation should the nurse provide?
A) Apply warm compresses to the breasts before bathing
B) Manually express small amounts of milk for comfort
C) Wear a tight-fitting, supportive bra continuously
D) Increase fluid intake to at least 3 liters daily
Answer: C) Wear a tight-fitting, supportive bra continuously
Rationale: For lactation suppression, interventions include wearing a tight bra 24 hours daily, applying
ice packs, avoiding breast stimulation, using refrigerated cabbage leaves in the bra, and avoiding warm
water on the breasts during showering. Breast stimulation (including pumping or expressing) will
encourage continued milk production.
, Question 9: A breastfeeding mother calls the clinic 10 days postpartum reporting breast tenderness,
fever of 101°F, and a reddened, hot area on one breast. What is the nurse's best response?
A) "Stop breastfeeding on the affected side immediately."
B) "Apply heat before feeding and ice after feeding."
C) "Continue breastfeeding and contact your provider for antibiotic evaluation."
D) "This is normal engorgement; pump both breasts frequently."
Answer: C) Continue breastfeeding and contact your provider for antibiotic evaluation
Rationale: These symptoms suggest mastitis, typically caused by Staphylococcus aureus occurring 2-3
weeks postpartum. Treatment includes antibiotics, continued breastfeeding (emptying the affected
breast helps clear infection), and alternating heat and cold packs. Discontinuing breastfeeding worsens
engorgement and infection.
Question 10: The nurse is assessing a postpartum client's fundus. To perform this assessment correctly,
the nurse should:
A) Palpate the fundus without supporting the lower uterine segment
B) Stabilize the uterus by placing a hand at the symphysis pubis
C) Massage the fundus before assessing its position
D) Assess fundal height in relation to the xiphoid process
Answer: B) Stabilize the uterus by placing a hand at the symphysis pubis
Rationale: Proper fundal assessment requires stabilizing the lower uterine segment with one hand
placed just above the symphysis pubis while the other hand palpates the fundus. This prevents uterine
prolapse and ensures accurate assessment of fundal height, position, and consistency.
Question 11: A postpartum client's fundus is boggy after voiding. What is the nurse's priority action?
A) Insert an indwelling urinary catheter
B) Perform fundal massage until firm
C) Notify the provider immediately
D) Administer oxytocin as ordered
Answer: B) Perform fundal massage until firm
Rationale: A boggy (soft) fundus indicates uterine atony, the leading cause of postpartum
hemorrhage. Fundal massage stimulates uterine contraction and should be performed until the uterus
becomes firm. After bladder emptying (which has already been done in this scenario), massage is the
priority intervention. Oxytocin may be needed if massage does not achieve sustained firmness.
Galen College of Nursing | Updated 2025-2026
Complete 300-Question Bank with Detailed Rationales
Section 1: Postpartum Assessment & BUBBLE-HE Framework
(Questions 1-40)
Question 1: The nurse is performing a postpartum assessment on a client who delivered vaginally 12
hours ago. The fundus is located 1 cm below the umbilicus, midline, and firm. Lochia is moderate
rubra. What is the appropriate nursing action?
A) Notify the healthcare provider immediately
B) Massage the fundus vigorously
C) Document the findings as normal
D) Prepare for ultrasound examination
Answer: C) Document the findings as normal
Rationale: Normal uterine involution occurs at a rate of 1-2 cm per day. At 12 hours postpartum, the
fundus should be at or slightly below the umbilicus. A firm, midline fundus with moderate rubra lochia
indicates adequate uterine contraction and normal involution. Vigorous massage is not indicated for a
firm fundus.
Question 2: A client who is 6 hours postpartum has a boggy uterus that is displaced to the right. What
is the nurse's priority action?
A) Administer oxytocin as ordered
B) Assist the client to void
C) Increase the IV fluid rate
D) Notify the healthcare provider
Answer: B) Assist the client to void
Rationale: A displaced uterus (typically to the right) is a classic sign of a full bladder. A distended
bladder lifts the uterus and prevents it from contracting effectively, leading to uterine atony and
increased risk of postpartum hemorrhage. The priority is to help the client void, then reassess the
fundus. Oxytocin may be needed after bladder emptying if the fundus remains boggy.
,Question 3: A postpartum client has saturated two perineal pads within one hour. The fundus is firm
and midline. What should the nurse suspect?
A) Normal postpartum bleeding
B) Uterine atony
C) Lacerations of the reproductive tract
D) Retained placental fragments
Answer: C) Lacerations of the reproductive tract
Rationale: When the fundus is firm but bleeding is excessive, the source is likely lacerations of the
cervix or vagina rather than uterine atony. A saturated pad within one hour is classified as heavy
bleeding requiring immediate investigation. Uterine atony presents with a boggy fundus, not a firm
one. Retained fragments typically cause late postpartum bleeding.
Question 4: The nurse is teaching a postpartum client about lochia progression. Which statement
indicates correct understanding?
A) "Lochia rubra should change to alba within 3 days."
B) "Lochia serosa is pinkish-brown and occurs around days 4-10."
C) "Lochia alba is bright red and lasts for 2 weeks."
D) "Lochia should stop completely by day 7."
Answer: B) Lochia serosa is pinkish-brown and occurs around days 4-10
Rationale: Lochia progresses through three stages: Rubra (bright red, days 1-3), Serosa (pinkish-
brown, days 4-10), and Alba (yellowish-white, days 10-14+). Lochia may continue for 3-6 weeks total.
Teaching patients this progression is essential for recognizing abnormal bleeding patterns.
Question 5: In the BUBBLE-HE postpartum assessment framework, which component includes
assessment of the perineum using REEDA?
A) Breasts
B) Uterus
C) Bladder
D) Episiotomy
Answer: D) Episiotomy
Rationale: BUBBLE-HE stands
for Breasts, U terus, B ladder, Bowels, L ochia, E pisiotomy, H emorrhoids, E motional status. The "E" for
Episiotomy includes perineal assessment using
REEDA: Redness, E dema, E cchymosis, D ischarge, A pproximation.
,Question 6: What is the REEDA assessment used for in postpartum care?
A) Assessing lochia color and amount
B) Evaluating episiotomy or perineal healing
C) Monitoring uterine involution
D) Assessing breast engorgement
Answer: B) Evaluating episiotomy or perineal healing
Rationale: REEDA is a systematic assessment tool for perineal healing following episiotomy or
laceration repair. It evaluates Redness, Edema, Ecchymosis, Discharge, and Approximation of wound
edges. Any abnormality should be reported to the healthcare provider.
Question 7: A postpartum client reports perineal pain rated 7/10. The nurse notes ecchymosis and
edema along the episiotomy site. Which intervention is most appropriate for the first 24 hours?
A) Apply warm sitz baths
B) Apply ice packs for 10-15 minutes alternating on and off
C) Administer oral opioids
D) Apply topical lidocaine gel
Answer: B) Apply ice packs for 10-15 minutes alternating on and off
Rationale: During the first 24 hours postpartum, ice packs are the standard intervention for perineal
pain and edema. Ice causes vasoconstriction, reducing swelling and providing local anesthesia. After
24 hours, warm sitz baths promote circulation and healing. Topical anesthetics may be used but
require assessment for intact skin.
Question 8: A non-breastfeeding mother asks how to suppress her milk production. Which
recommendation should the nurse provide?
A) Apply warm compresses to the breasts before bathing
B) Manually express small amounts of milk for comfort
C) Wear a tight-fitting, supportive bra continuously
D) Increase fluid intake to at least 3 liters daily
Answer: C) Wear a tight-fitting, supportive bra continuously
Rationale: For lactation suppression, interventions include wearing a tight bra 24 hours daily, applying
ice packs, avoiding breast stimulation, using refrigerated cabbage leaves in the bra, and avoiding warm
water on the breasts during showering. Breast stimulation (including pumping or expressing) will
encourage continued milk production.
, Question 9: A breastfeeding mother calls the clinic 10 days postpartum reporting breast tenderness,
fever of 101°F, and a reddened, hot area on one breast. What is the nurse's best response?
A) "Stop breastfeeding on the affected side immediately."
B) "Apply heat before feeding and ice after feeding."
C) "Continue breastfeeding and contact your provider for antibiotic evaluation."
D) "This is normal engorgement; pump both breasts frequently."
Answer: C) Continue breastfeeding and contact your provider for antibiotic evaluation
Rationale: These symptoms suggest mastitis, typically caused by Staphylococcus aureus occurring 2-3
weeks postpartum. Treatment includes antibiotics, continued breastfeeding (emptying the affected
breast helps clear infection), and alternating heat and cold packs. Discontinuing breastfeeding worsens
engorgement and infection.
Question 10: The nurse is assessing a postpartum client's fundus. To perform this assessment correctly,
the nurse should:
A) Palpate the fundus without supporting the lower uterine segment
B) Stabilize the uterus by placing a hand at the symphysis pubis
C) Massage the fundus before assessing its position
D) Assess fundal height in relation to the xiphoid process
Answer: B) Stabilize the uterus by placing a hand at the symphysis pubis
Rationale: Proper fundal assessment requires stabilizing the lower uterine segment with one hand
placed just above the symphysis pubis while the other hand palpates the fundus. This prevents uterine
prolapse and ensures accurate assessment of fundal height, position, and consistency.
Question 11: A postpartum client's fundus is boggy after voiding. What is the nurse's priority action?
A) Insert an indwelling urinary catheter
B) Perform fundal massage until firm
C) Notify the provider immediately
D) Administer oxytocin as ordered
Answer: B) Perform fundal massage until firm
Rationale: A boggy (soft) fundus indicates uterine atony, the leading cause of postpartum
hemorrhage. Fundal massage stimulates uterine contraction and should be performed until the uterus
becomes firm. After bladder emptying (which has already been done in this scenario), massage is the
priority intervention. Oxytocin may be needed if massage does not achieve sustained firmness.
