NSG 4525 POSTPARTUM QUESTIONS AND ANSWERS
A nurse is providing discharge teaching to a client who is 3 days postoperative following
a cesarean birth. Which of the following client statement should indicate to the nurse the
teaching is effective? SATA
-"I am likely to have a fever during the first week I am home."
-"I will resume taking my prenatal vitamins."
-"I will call my provider if I have discharge from my incision."
-"I should not have unrelieved pain in my abdomen."
-"I will rest in a recliner until my incision is healed." - Answers - -"I will resume taking my
prenatal vitamins."
-"I will call my provider if I have discharge from my incision."
-"I should not have unrelieved pain in my abdomen."
A nurse is performing a physical examination of a client who is 1 day postpartum. Which
of the following findings requires immediate interventions?
-Decreased urge to void
-Increased urine output
-Displaced fundus from the midline
-Fundal height below the umbilicus - Answers - -Displaced fundus from the midline
A distended bladder can cause uterine atony and lateral displacement of the fundus
from the midline of the lower abdomen, usually to the right. This requires immediate
intervention because the distended bladder pushes the uterus up and to the side, which
prevents it from contracting firmly. Uterine atony results from the inability of the uterine
muscle to contract adequately after birth. This can lead to postpartum hemorrhage.
A nurse is caring for a client who is 1 hr postpartum and observes a large amount of
lochia rubra and several small clots on the client's perineal pad. The fundus is midline
and firm at the umbilicus. Which of the following actions should the nurse take?
-Document the findings and continue to monitor the client.
-Notify the client's provider.
-Increase the frequency of fundal massage.
-Encourage the client to empty her bladder. - Answers - -Document the findings and
continue to monitor the client.
These are expected findings. At 1 hr postpartum, lochia rubra should be intermittent and
associated with uterine contractions. The volume of lochia resembles that of a heavy
menstrual period. Small clots are common. The nurse should document the findings and
continue to monitor the client.
A nurse is caring for a postpartum client who tells the nurse that she does not want any
more children. The client asks which birth control method the nurse would recommend.
Which of the following responses should the nurse make?
-"It's your choice, of course, but birth control pills are the most reliable."
-"Your provider usually recommends a diaphragm and spermicidal cream."
-"I'd consider an intrauterine device. You won't have to worry about pregnancy."
, -"Let's talk about the available options and go from there." - Answers - -"Let's talk about
the available options and go from there."
This response illustrates the therapeutic communication technique of formulating a plan
of action. It demonstrates the nurse's willingness to provide information so that the client
can make an informed choice that will meet her needs at this time.
A nurse is caring for a client who experienced a vaginal birth 12 hr ago. The nurse
recognizes the client is in the dependent, taking in phase of maternal postpartum
adjustment. Which of the following findings should the nurse expect during this phase?
-Expressions of excitement
-Lack of appetite
-Focus on the family unit and its members
-Eagerness to learn newborn care skills - Answers - -Expressions of excitement
Expressing excitement and being talkative are characteristic of this phase.
A nurse is caring for a client who is 2 hr postpartum. The nurse notes that the client
soaked a perineal pad in 10 min, the client's skin color is ashen, and she states she
feels weak and light headed. After applying oxygen via nonrebreather face mask at 10
L/min which of the following actions should the nurse take next?
-Insert an indwelling urinary catheter.
-Administer oxytocin by continuous IV infusion.
-Tilt the client onto her right side with her legs elevated to at least 30°.
-Massage the client's fundus to promote contractions. - Answers - -Massage the client's
fundus to promote contractions.
A soaked perineal pad in less than 15 min, ashen skin color, and report of weakness
and light headedness can indicate that the client is at greatest risk for hypovolemic
shock. Therefore, the next action the nurse should take is to massage the client's
fundus to expel blood clots and promote uterine contraction to stop the bleeding.
A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of
the following findings indicates the client's bladder is distended?
-Client report of frequent uterine contractions
-Less than 2.5 cm of rubra lochia on perineal pad
-Fundus palpable to right of midline
-Client report of increased thirst - Answers - -Fundus palpable to right of midline
Bladder distention results in uterine displacement, pushing the fundus above the
umbilicus and away from the midline. The fundus might feel boggy to palpation and
does not contract normally.
A nurse is caring for a client who is 7 days postpartum and calls the clinic to report pain
and redness of her left calf. Besides seeing her provider, which of the following
interventions should the nurse suggest?
-Flex her knee while resting.
-Massage the area.
-Elevate her leg.
-Apply cold compresses. - Answers - -Elevate her leg.
A nurse is providing discharge teaching to a client who is 3 days postoperative following
a cesarean birth. Which of the following client statement should indicate to the nurse the
teaching is effective? SATA
-"I am likely to have a fever during the first week I am home."
-"I will resume taking my prenatal vitamins."
-"I will call my provider if I have discharge from my incision."
-"I should not have unrelieved pain in my abdomen."
-"I will rest in a recliner until my incision is healed." - Answers - -"I will resume taking my
prenatal vitamins."
-"I will call my provider if I have discharge from my incision."
-"I should not have unrelieved pain in my abdomen."
A nurse is performing a physical examination of a client who is 1 day postpartum. Which
of the following findings requires immediate interventions?
-Decreased urge to void
-Increased urine output
-Displaced fundus from the midline
-Fundal height below the umbilicus - Answers - -Displaced fundus from the midline
A distended bladder can cause uterine atony and lateral displacement of the fundus
from the midline of the lower abdomen, usually to the right. This requires immediate
intervention because the distended bladder pushes the uterus up and to the side, which
prevents it from contracting firmly. Uterine atony results from the inability of the uterine
muscle to contract adequately after birth. This can lead to postpartum hemorrhage.
A nurse is caring for a client who is 1 hr postpartum and observes a large amount of
lochia rubra and several small clots on the client's perineal pad. The fundus is midline
and firm at the umbilicus. Which of the following actions should the nurse take?
-Document the findings and continue to monitor the client.
-Notify the client's provider.
-Increase the frequency of fundal massage.
-Encourage the client to empty her bladder. - Answers - -Document the findings and
continue to monitor the client.
These are expected findings. At 1 hr postpartum, lochia rubra should be intermittent and
associated with uterine contractions. The volume of lochia resembles that of a heavy
menstrual period. Small clots are common. The nurse should document the findings and
continue to monitor the client.
A nurse is caring for a postpartum client who tells the nurse that she does not want any
more children. The client asks which birth control method the nurse would recommend.
Which of the following responses should the nurse make?
-"It's your choice, of course, but birth control pills are the most reliable."
-"Your provider usually recommends a diaphragm and spermicidal cream."
-"I'd consider an intrauterine device. You won't have to worry about pregnancy."
, -"Let's talk about the available options and go from there." - Answers - -"Let's talk about
the available options and go from there."
This response illustrates the therapeutic communication technique of formulating a plan
of action. It demonstrates the nurse's willingness to provide information so that the client
can make an informed choice that will meet her needs at this time.
A nurse is caring for a client who experienced a vaginal birth 12 hr ago. The nurse
recognizes the client is in the dependent, taking in phase of maternal postpartum
adjustment. Which of the following findings should the nurse expect during this phase?
-Expressions of excitement
-Lack of appetite
-Focus on the family unit and its members
-Eagerness to learn newborn care skills - Answers - -Expressions of excitement
Expressing excitement and being talkative are characteristic of this phase.
A nurse is caring for a client who is 2 hr postpartum. The nurse notes that the client
soaked a perineal pad in 10 min, the client's skin color is ashen, and she states she
feels weak and light headed. After applying oxygen via nonrebreather face mask at 10
L/min which of the following actions should the nurse take next?
-Insert an indwelling urinary catheter.
-Administer oxytocin by continuous IV infusion.
-Tilt the client onto her right side with her legs elevated to at least 30°.
-Massage the client's fundus to promote contractions. - Answers - -Massage the client's
fundus to promote contractions.
A soaked perineal pad in less than 15 min, ashen skin color, and report of weakness
and light headedness can indicate that the client is at greatest risk for hypovolemic
shock. Therefore, the next action the nurse should take is to massage the client's
fundus to expel blood clots and promote uterine contraction to stop the bleeding.
A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of
the following findings indicates the client's bladder is distended?
-Client report of frequent uterine contractions
-Less than 2.5 cm of rubra lochia on perineal pad
-Fundus palpable to right of midline
-Client report of increased thirst - Answers - -Fundus palpable to right of midline
Bladder distention results in uterine displacement, pushing the fundus above the
umbilicus and away from the midline. The fundus might feel boggy to palpation and
does not contract normally.
A nurse is caring for a client who is 7 days postpartum and calls the clinic to report pain
and redness of her left calf. Besides seeing her provider, which of the following
interventions should the nurse suggest?
-Flex her knee while resting.
-Massage the area.
-Elevate her leg.
-Apply cold compresses. - Answers - -Elevate her leg.
