NUR 254 Exam 2 Review – Alternate Set (Questions 1–150)
Galen College of Nursing | Updated 2025–2026
Section 1: Postpartum Assessment & Complications (Questions 1–30)
Question 1: A nurse is assessing a client who is 8 hours post-vaginal delivery. The fundus is firm,
midline, and at the level of the umbilicus. Lochia is moderate rubra with a few small clots. Which action
should the nurse take?
A) Notify the provider immediately
B) Massage the fundus vigorously
C) Document the findings as normal
D) Increase oxytocin infusion
Answer: C
Rationale: At 8 hours postpartum, a firm, midline fundus at the umbilicus with moderate rubra lochia
and small clots is expected. Small clots (<2 cm) are normal in early postpartum. No intervention is
required.
Question 2: A client who is 4 hours postpartum has a fundus that is boggy and deviated to the left.
She denies the urge to void. What is the priority nursing action?
A) Administer oxytocin IV
B) Assist the client to the bathroom to void
C) Notify the healthcare provider
D) Perform fundal massage without voiding
Answer: B
Rationale: A displaced boggy fundus typically indicates a full bladder. The priority is to help the client
void. After voiding, the fundus should be reassessed. If still boggy, fundal massage and oxytocin may
,be indicated.
Question 3: A postpartum client reports soaking two perineal pads within 30 minutes. The fundus is
firm and midline. What is the nurse's best next action?
A) Administer methylergonovine
B) Perform bimanual uterine massage
C) Assess the perineum and vagina for lacerations
D) Increase the IV oxytocin rate
Answer: C
Rationale: A firm fundus with heavy bleeding suggests lacerations of the cervix, vagina, or perineum
rather than uterine atony. The nurse should inspect the perineum and notify the provider for possible
repair.
Question 4: A nurse is providing discharge teaching to a postpartum client who delivered 2 days ago.
Which statement by the client indicates a need for further teaching about lochia?
A) "My lochia will change from red to pink to white"
B) "I should call my doctor if my lochia has a bad smell"
C) "If I start bleeding bright red again at day 10, that's normal"
D) "I should use pads, not tampons, for lochia"
Answer: C
Rationale: A return to bright red bleeding after the lochia has progressed to serosa or alba is
abnormal and may indicate late postpartum hemorrhage from retained placental fragments. The client
should report this to her provider.
Question 5: A postpartum client is 2 hours after a vacuum-assisted delivery. She has a third-degree
perineal laceration. Which nursing intervention is most important?
,A) Apply warm sitz baths immediately
B) Apply ice packs to the perineum
C) Administer a stool softener now
D) Encourage the client to bear down
Answer: B
Rationale: During the first 24 hours postpartum, ice packs are the standard intervention for perineal
pain and edema. Warm sitz baths are started after 24 hours. Stool softeners are important but not the
most immediate priority.
Question 6: A breastfeeding client at 3 weeks postpartum reports a fever of 102°F, chills, and a painful
red area on her right breast. She continues to breastfeed. What is the most appropriate
recommendation?
A) Stop breastfeeding on the right side
B) Apply ice packs before feeding
C) Continue breastfeeding and start antibiotics as prescribed
D) Pump and discard milk from the right breast
Answer: C
Rationale: Mastitis requires continued breast emptying and antibiotics. The mother should continue
breastfeeding on the affected side. Stopping breastfeeding worsens engorgement and infection.
Question 7: A client who delivered 12 hours ago has a blood pressure of 80/50 mm Hg, heart rate 130
bpm, and respiratory rate 24/min. Lochia is scant. The fundus is firm. What should the nurse suspect?
A) Normal postpartum changes
B) Uterine atony
C) Internal hemorrhage (broad ligament hematoma)
D) Pulmonary embolism
Answer: C
, Rationale: Tachycardia and hypotension with scant external bleeding and a firm fundus suggest
internal hemorrhage (e.g., broad ligament hematoma or intra-abdominal bleeding). The provider must
be notified immediately.
Question 8: A nurse is assessing a client who delivered 6 hours ago. The client's bladder is distended,
and the fundus is firm at the umbilicus. What is the priority action?
A) Insert an indwelling urinary catheter
B) Assist the client to void
C) Notify the provider
D) Massage the fundus
Answer: B
Rationale: A distended bladder requires emptying. The nurse should assist the client to void. A Foley
catheter is only needed if the client cannot void spontaneously. The fundus is firm, so massage is not
needed.
Question 9: A postpartum client who is Rh-negative gave birth to an Rh-positive infant 18 hours ago.
The nurse notes that RhoGAM has not been given. What should the nurse do first?
A) Document the finding
B) Administer RhoGAM immediately
C) Notify the provider
D) Request a repeat blood type on the infant
Answer: B
Rationale: RhoGAM should be given within 72 hours of delivery. The nurse should administer it
immediately as ordered. Delaying further increases the risk of Rh sensitization.
Question 10: A client who delivered 5 days ago calls the clinic. She reports a fever of 101°F and foul-
smelling lochia. She has not had a bowel movement since delivery. What is the priority instruction?
Galen College of Nursing | Updated 2025–2026
Section 1: Postpartum Assessment & Complications (Questions 1–30)
Question 1: A nurse is assessing a client who is 8 hours post-vaginal delivery. The fundus is firm,
midline, and at the level of the umbilicus. Lochia is moderate rubra with a few small clots. Which action
should the nurse take?
A) Notify the provider immediately
B) Massage the fundus vigorously
C) Document the findings as normal
D) Increase oxytocin infusion
Answer: C
Rationale: At 8 hours postpartum, a firm, midline fundus at the umbilicus with moderate rubra lochia
and small clots is expected. Small clots (<2 cm) are normal in early postpartum. No intervention is
required.
Question 2: A client who is 4 hours postpartum has a fundus that is boggy and deviated to the left.
She denies the urge to void. What is the priority nursing action?
A) Administer oxytocin IV
B) Assist the client to the bathroom to void
C) Notify the healthcare provider
D) Perform fundal massage without voiding
Answer: B
Rationale: A displaced boggy fundus typically indicates a full bladder. The priority is to help the client
void. After voiding, the fundus should be reassessed. If still boggy, fundal massage and oxytocin may
,be indicated.
Question 3: A postpartum client reports soaking two perineal pads within 30 minutes. The fundus is
firm and midline. What is the nurse's best next action?
A) Administer methylergonovine
B) Perform bimanual uterine massage
C) Assess the perineum and vagina for lacerations
D) Increase the IV oxytocin rate
Answer: C
Rationale: A firm fundus with heavy bleeding suggests lacerations of the cervix, vagina, or perineum
rather than uterine atony. The nurse should inspect the perineum and notify the provider for possible
repair.
Question 4: A nurse is providing discharge teaching to a postpartum client who delivered 2 days ago.
Which statement by the client indicates a need for further teaching about lochia?
A) "My lochia will change from red to pink to white"
B) "I should call my doctor if my lochia has a bad smell"
C) "If I start bleeding bright red again at day 10, that's normal"
D) "I should use pads, not tampons, for lochia"
Answer: C
Rationale: A return to bright red bleeding after the lochia has progressed to serosa or alba is
abnormal and may indicate late postpartum hemorrhage from retained placental fragments. The client
should report this to her provider.
Question 5: A postpartum client is 2 hours after a vacuum-assisted delivery. She has a third-degree
perineal laceration. Which nursing intervention is most important?
,A) Apply warm sitz baths immediately
B) Apply ice packs to the perineum
C) Administer a stool softener now
D) Encourage the client to bear down
Answer: B
Rationale: During the first 24 hours postpartum, ice packs are the standard intervention for perineal
pain and edema. Warm sitz baths are started after 24 hours. Stool softeners are important but not the
most immediate priority.
Question 6: A breastfeeding client at 3 weeks postpartum reports a fever of 102°F, chills, and a painful
red area on her right breast. She continues to breastfeed. What is the most appropriate
recommendation?
A) Stop breastfeeding on the right side
B) Apply ice packs before feeding
C) Continue breastfeeding and start antibiotics as prescribed
D) Pump and discard milk from the right breast
Answer: C
Rationale: Mastitis requires continued breast emptying and antibiotics. The mother should continue
breastfeeding on the affected side. Stopping breastfeeding worsens engorgement and infection.
Question 7: A client who delivered 12 hours ago has a blood pressure of 80/50 mm Hg, heart rate 130
bpm, and respiratory rate 24/min. Lochia is scant. The fundus is firm. What should the nurse suspect?
A) Normal postpartum changes
B) Uterine atony
C) Internal hemorrhage (broad ligament hematoma)
D) Pulmonary embolism
Answer: C
, Rationale: Tachycardia and hypotension with scant external bleeding and a firm fundus suggest
internal hemorrhage (e.g., broad ligament hematoma or intra-abdominal bleeding). The provider must
be notified immediately.
Question 8: A nurse is assessing a client who delivered 6 hours ago. The client's bladder is distended,
and the fundus is firm at the umbilicus. What is the priority action?
A) Insert an indwelling urinary catheter
B) Assist the client to void
C) Notify the provider
D) Massage the fundus
Answer: B
Rationale: A distended bladder requires emptying. The nurse should assist the client to void. A Foley
catheter is only needed if the client cannot void spontaneously. The fundus is firm, so massage is not
needed.
Question 9: A postpartum client who is Rh-negative gave birth to an Rh-positive infant 18 hours ago.
The nurse notes that RhoGAM has not been given. What should the nurse do first?
A) Document the finding
B) Administer RhoGAM immediately
C) Notify the provider
D) Request a repeat blood type on the infant
Answer: B
Rationale: RhoGAM should be given within 72 hours of delivery. The nurse should administer it
immediately as ordered. Delaying further increases the risk of Rh sensitization.
Question 10: A client who delivered 5 days ago calls the clinic. She reports a fever of 101°F and foul-
smelling lochia. She has not had a bowel movement since delivery. What is the priority instruction?
