NRSG 3302 Women & Families - Postpartum Psychiological
Assessments Ch. 12 Questions With Complete Solutions
A nurse is caring for a client in the first hour following a vaginal
delivery. What is the priority nursing intervention?
A. Facilitate bonding between the mother and infant.
B. Assess the fundus for location, position, and tone.
C. Administer pain medications.
D. Inspect the perineum for tearing. Correct Answers A. (not
wrong, but there is a more right answer) Facilitate bonding
between the mother and infant.
Rationale: Facilitating bonding is the priority in the first hour
following delivery.
B. (Correct) Assess the fundus for location, position, and tone.
Rationale: The risk for postpartum hemorrhage is the greatest
within the first hour following delivery. The fundus should be
assessed for location, position, and tone every 15 minutes for the
first hour.
C. Administer pain medications.
Rationale: Pain medication may be ordered, but is not the
priority of the nurse at this time.
D: Inspect the perineum for tearing.
,Rationale: Careful inspection of the perineum is the job of the
healthcare provider immediately following delivery.
A nurse is caring for a client in the immediate postpartum
period. Upon assessment, the nurse notes heavy bleeding and a
boggy uterus that does not respond to fundal massage. What are
the priority nursing actions? Place in the correct order.
1. Increase the frequency of vital signs.
2. Notify the physician or midwife of excessive blood loss.
3. Perform fundal massage.
4. Titrate the standing order of oxytocin as appropriate. Correct
Answers 1. Perform fundal massage.
2. Titrate the standing order of oxytocin as appropriate.
3. Notify the physician or midwife of excessive blood loss.
4. Increase the frequency of vital signs.
Rationale: Immediate nursing actions for excessive bleeding
include massaging the uterus if it is boggy and following the
standing order for oxytocin administration, then notifying the
healthcare provider. While awaiting the arrival of the evaluating
clinician, the bedside nurse should increase the frequency of
vital signs.
A nurse is caring for a G2P2002 client in the initial hour after
giving birth. What are the appropriate nursing interventions to
be taken with this client? Select all that apply.
1. Assess the uterus for location, position, and tone of fundus
every 15 minutes.
2. Titrate IV oxytocin infusion rate to uterine tone.
, 3. Provide information regarding afterpains.
4. Assess lochia for color, amount, and odor.
5. Inspect the inside of the vagina for tearing. Correct Answers
1. (Correct) Assess the uterus for location, position, and tone of
fundus every 15 minutes.
Rationale: Uterine assessment should be done every 15 minutes
for the first hour after delivery.
2. (Correct) Titrate IV oxytocin infusion rate to uterine tone.
Rationale: Universal active management of the third stage of
labor includes administration of IV oxytocin.
3. (Correct) Provide information regarding afterpains.
Rationale: Muliparous women often experience moderate to
severe cramp-like pains associated with the uterus contracting
after delivery.
4. (Correct) Assess lochia for color, amount, and odor.
Rationale: Lochia should be assessed at the same time the uterus
is assessed.
5. Inspect the inside of the vagina for tearing.
Rationale: Vaginal inspection is done by the healthcare provider
after delivery of the infant.
Assessments Ch. 12 Questions With Complete Solutions
A nurse is caring for a client in the first hour following a vaginal
delivery. What is the priority nursing intervention?
A. Facilitate bonding between the mother and infant.
B. Assess the fundus for location, position, and tone.
C. Administer pain medications.
D. Inspect the perineum for tearing. Correct Answers A. (not
wrong, but there is a more right answer) Facilitate bonding
between the mother and infant.
Rationale: Facilitating bonding is the priority in the first hour
following delivery.
B. (Correct) Assess the fundus for location, position, and tone.
Rationale: The risk for postpartum hemorrhage is the greatest
within the first hour following delivery. The fundus should be
assessed for location, position, and tone every 15 minutes for the
first hour.
C. Administer pain medications.
Rationale: Pain medication may be ordered, but is not the
priority of the nurse at this time.
D: Inspect the perineum for tearing.
,Rationale: Careful inspection of the perineum is the job of the
healthcare provider immediately following delivery.
A nurse is caring for a client in the immediate postpartum
period. Upon assessment, the nurse notes heavy bleeding and a
boggy uterus that does not respond to fundal massage. What are
the priority nursing actions? Place in the correct order.
1. Increase the frequency of vital signs.
2. Notify the physician or midwife of excessive blood loss.
3. Perform fundal massage.
4. Titrate the standing order of oxytocin as appropriate. Correct
Answers 1. Perform fundal massage.
2. Titrate the standing order of oxytocin as appropriate.
3. Notify the physician or midwife of excessive blood loss.
4. Increase the frequency of vital signs.
Rationale: Immediate nursing actions for excessive bleeding
include massaging the uterus if it is boggy and following the
standing order for oxytocin administration, then notifying the
healthcare provider. While awaiting the arrival of the evaluating
clinician, the bedside nurse should increase the frequency of
vital signs.
A nurse is caring for a G2P2002 client in the initial hour after
giving birth. What are the appropriate nursing interventions to
be taken with this client? Select all that apply.
1. Assess the uterus for location, position, and tone of fundus
every 15 minutes.
2. Titrate IV oxytocin infusion rate to uterine tone.
, 3. Provide information regarding afterpains.
4. Assess lochia for color, amount, and odor.
5. Inspect the inside of the vagina for tearing. Correct Answers
1. (Correct) Assess the uterus for location, position, and tone of
fundus every 15 minutes.
Rationale: Uterine assessment should be done every 15 minutes
for the first hour after delivery.
2. (Correct) Titrate IV oxytocin infusion rate to uterine tone.
Rationale: Universal active management of the third stage of
labor includes administration of IV oxytocin.
3. (Correct) Provide information regarding afterpains.
Rationale: Muliparous women often experience moderate to
severe cramp-like pains associated with the uterus contracting
after delivery.
4. (Correct) Assess lochia for color, amount, and odor.
Rationale: Lochia should be assessed at the same time the uterus
is assessed.
5. Inspect the inside of the vagina for tearing.
Rationale: Vaginal inspection is done by the healthcare provider
after delivery of the infant.
