References
Nursing Care of the Post-partum Patient
1. Mrs. Smith delivered a 4000 gram infant by spontaneous vaginal delivery. Nursing
assessments during the 4th stage of labor are based on the knowledge that:
a. The infant's size predisposes the mother to postpartum hemorrhage.
b. Lochia can be predicted to be heavy for the first 24 hours.
c. Her temperature may be elevated for the first 48 hours.
d. She will require an undisturbed period of rest.
2. When palpating the abdomen, the nurse has difficulty locating the fundus because it is "boggy"
or uncontracted. The first nursing action should be to:
a. Notify the physician.
b. Start oxytocin.
c. Massage the fundus.
d. Catheterize the patient.
3. The fundus of Mrs. Roland is firm, midline, and at the level of the umbilicus. Lochia is saturating
more than one peripad per hour. Nursing intervention is based on the knowledge that:
a. If the fundus is firm, there is no cause to suspect hemorrhage.
b. Excessive bleeding may be caused by lacerations of the birth canal.
c. Clots should be expressed from the uterus.
d. Oxytocin should be added to the IV fluid.
4. Mrs. Thomas complains of severe pain and rectal pressure 2 hours after the birth of her infant.
The nursing assessment is based on the knowledge that:
a. Constipation is common due to dehydration during labor.
b. Local anesthesia is wearing off.
c. There may be bleeding into the soft tissue.
d. Episiotomies may extend into the rectal sphincter.
5. At the morning assessment, Mrs. Perkins has a brachial pulse of 138. She delivered a baby girl
24 hours ago. The fundus is firm and lochia is moderate. Which additional nursing
assessments should be given priority?
a. Length of labor and fluid intake since birth.
b. Mucous membranes and skin temperature.
c. Estimated blood loss, hemoglobin and hematocrit.
d. Respiratory rate and interaction with the infant.
6. Nursing interventions for Mrs. Perkins are based on the knowledge that tachycardia may
indicate all of the following except:
a. Anemia.
b. Decreased cardiac output.
c. Excitement.
d. Remobilization of fluid.
, References
7. Mrs. Perkins also states that she feels lightheaded and "faint" when she gets up.
Additional nursing assessments should include:
a. Time of her last meal.
b. Temperature and respiratory rate.
c. Blood pressure in sitting position.
d. Blood pressure in the opposite arm.
8. Before discharge the nurse assists Mrs. Jones to palpate her fundus. Mrs. Jones
asks how long she will be able to feel the uterus in the abdomen. The nurse's response
is based on the knowledge that:
a. The uterus is permanently felt in the abdomen after childbirth.
b. In two days the uterus should not be palpable.
c. The uterus descends about 1 centimeter per day.
d. There is no need to palpate the fundus after 12 hours.
9. Mrs. Jones asks how she will know if lochia is excessive. An appropriate response
is based on the knowledge that:
a. A saturated pad contains approximately 100 ml.s of blood.
b. There should be no lochia after three days.
c. There is no need for concern about hemorrhage following the fourth stage of labor.
d. Only the physician can answer this question.
10. A week after discharge, Mrs. Jones stops by the outpatient clinic to report that lochia
is dark brown in color and has a foul odor. Priority nursing actions include:
a. Remind Mrs. Jones that this is expected during the second week.
b. Determine if she has burning on urination.
c. Review the correct perineal hygiene.
d. Assess for increased temperature and pelvic discomfort.
11. Nursing interventions for Mrs. Jones are based on the knowledge that:
a. Bacteria ascend through the urethra and into the bladder.
b. Infection may occur at the site of placental attachment.
c. The episiotomy should be assessed for approximation.
d. Mrs. Jones is experiencing expected "postpartum" blues."
12. Mrs. Lozano is unable to urinate following the birth of her baby girl. Nursing actions
include all of the following except:
a. Assist her to ambulate to the bathroom.
b. Suggest she spray warm water over her perineum.
c. Assess her fundus for location and firmness.
d. Do not intervene until she has a strong urge to void.
13. Mrs. Armstrong is a young primipara who gave birth to a baby boy 18 hours ago.
Expected behaviors during this time might include all of the following except:
a. She spends a lot of time talking about her labor.
b. She has many questions about infant care.
c. She touches the infant with fingertips only.
d. She seems primarily concerned about her own needs.
Nursing Care of the Post-partum Patient
1. Mrs. Smith delivered a 4000 gram infant by spontaneous vaginal delivery. Nursing
assessments during the 4th stage of labor are based on the knowledge that:
a. The infant's size predisposes the mother to postpartum hemorrhage.
b. Lochia can be predicted to be heavy for the first 24 hours.
c. Her temperature may be elevated for the first 48 hours.
d. She will require an undisturbed period of rest.
2. When palpating the abdomen, the nurse has difficulty locating the fundus because it is "boggy"
or uncontracted. The first nursing action should be to:
a. Notify the physician.
b. Start oxytocin.
c. Massage the fundus.
d. Catheterize the patient.
3. The fundus of Mrs. Roland is firm, midline, and at the level of the umbilicus. Lochia is saturating
more than one peripad per hour. Nursing intervention is based on the knowledge that:
a. If the fundus is firm, there is no cause to suspect hemorrhage.
b. Excessive bleeding may be caused by lacerations of the birth canal.
c. Clots should be expressed from the uterus.
d. Oxytocin should be added to the IV fluid.
4. Mrs. Thomas complains of severe pain and rectal pressure 2 hours after the birth of her infant.
The nursing assessment is based on the knowledge that:
a. Constipation is common due to dehydration during labor.
b. Local anesthesia is wearing off.
c. There may be bleeding into the soft tissue.
d. Episiotomies may extend into the rectal sphincter.
5. At the morning assessment, Mrs. Perkins has a brachial pulse of 138. She delivered a baby girl
24 hours ago. The fundus is firm and lochia is moderate. Which additional nursing
assessments should be given priority?
a. Length of labor and fluid intake since birth.
b. Mucous membranes and skin temperature.
c. Estimated blood loss, hemoglobin and hematocrit.
d. Respiratory rate and interaction with the infant.
6. Nursing interventions for Mrs. Perkins are based on the knowledge that tachycardia may
indicate all of the following except:
a. Anemia.
b. Decreased cardiac output.
c. Excitement.
d. Remobilization of fluid.
, References
7. Mrs. Perkins also states that she feels lightheaded and "faint" when she gets up.
Additional nursing assessments should include:
a. Time of her last meal.
b. Temperature and respiratory rate.
c. Blood pressure in sitting position.
d. Blood pressure in the opposite arm.
8. Before discharge the nurse assists Mrs. Jones to palpate her fundus. Mrs. Jones
asks how long she will be able to feel the uterus in the abdomen. The nurse's response
is based on the knowledge that:
a. The uterus is permanently felt in the abdomen after childbirth.
b. In two days the uterus should not be palpable.
c. The uterus descends about 1 centimeter per day.
d. There is no need to palpate the fundus after 12 hours.
9. Mrs. Jones asks how she will know if lochia is excessive. An appropriate response
is based on the knowledge that:
a. A saturated pad contains approximately 100 ml.s of blood.
b. There should be no lochia after three days.
c. There is no need for concern about hemorrhage following the fourth stage of labor.
d. Only the physician can answer this question.
10. A week after discharge, Mrs. Jones stops by the outpatient clinic to report that lochia
is dark brown in color and has a foul odor. Priority nursing actions include:
a. Remind Mrs. Jones that this is expected during the second week.
b. Determine if she has burning on urination.
c. Review the correct perineal hygiene.
d. Assess for increased temperature and pelvic discomfort.
11. Nursing interventions for Mrs. Jones are based on the knowledge that:
a. Bacteria ascend through the urethra and into the bladder.
b. Infection may occur at the site of placental attachment.
c. The episiotomy should be assessed for approximation.
d. Mrs. Jones is experiencing expected "postpartum" blues."
12. Mrs. Lozano is unable to urinate following the birth of her baby girl. Nursing actions
include all of the following except:
a. Assist her to ambulate to the bathroom.
b. Suggest she spray warm water over her perineum.
c. Assess her fundus for location and firmness.
d. Do not intervene until she has a strong urge to void.
13. Mrs. Armstrong is a young primipara who gave birth to a baby boy 18 hours ago.
Expected behaviors during this time might include all of the following except:
a. She spends a lot of time talking about her labor.
b. She has many questions about infant care.
c. She touches the infant with fingertips only.
d. She seems primarily concerned about her own needs.
