,BSN 346 Shadow Health Uncomplicated Delivery
(Daanis LaFontaine) | 100% Score | 2026
Updated
1. Which of the following is the priority nursing assessment immediately after an uncomplicated vaginal
delivery?
A) Palpate the fundus for firmness, location, and uterine tone
B) Inspect the perineum for edema
C) Obtain a full set of vital signs
D) Assess the breasts for engorgement
Correct Answer: Palpate the fundus for firmness, location, and uterine tone
Rationale: Early postpartum hemorrhage most often results from uterine atony. Assessing the fundus
confirms the uterus is contracted and midline, which compresses bleeding vessels. Vital signs and
perineal inspection are important but secondary to ensuring uterine hemostasis.
2. The nurse is caring for Daanis LaFontaine, who reports moderate perineal pain after a spontaneous
vaginal delivery with a second-degree laceration. Which nonpharmacologic measure should the nurse
offer first?
A) Suggest a warm sitz bath immediately
B) Apply an ice pack to the perineum for the first 24 hours
C) Administer a prescribed oral opioid
D) Place a donut cushion under the client
Correct Answer: Apply an ice pack to the perineum for the first 24 hours
Rationale: Cold therapy constricts blood vessels, reduces edema, and provides analgesia during the
initial 24 hours after delivery. Heat and sitz baths are introduced after 24 hours. Oral opioids require an
order and are not a nonpharmacologic measure.
,3. A postpartum client’s fundus is palpated two fingerbreadths above the umbilicus and deviated to the
right. The nurse should first
A) Massage the fundus vigorously
B) Administer oxytocin intravenously
C) Assist the client to empty her bladder
D) Notify the health care provider immediately
Correct Answer: Assist the client to empty her bladder
Rationale: A full bladder displaces the uterus upward and laterally, interfering with contraction.
Emptying the bladder often returns the fundus to midline at or below the umbilicus. Fundal massage
may follow if the uterus remains boggy.
4. During a home visit, the nurse instructs Daanis to monitor her lochia. Which description indicates she
should contact her provider?
A) Lochia rubra for the first 3 days
B) Lochia serosa from day 4 to day 10
C) Lochia alba from day 10 to week 6
D) A sudden increase in bright red bleeding after lochia has lightened
Correct Answer: A sudden increase in bright red bleeding after lochia has lightened
Rationale: Return to heavy, bright red bleeding (lochia rubra) after it has transitioned to serosa or alba
suggests late postpartum hemorrhage, often from retained placental fragments or infection. This
requires immediate evaluation.
5. The nurse is assessing Daanis LaFontaine’s breasts on postpartum day 2. The client reports mild
tenderness and the breasts are warm, firm, and secreting colostrum. The nurse identifies these findings
as
A) Physiological engorgement as milk production transitions
B) Mastitis requiring antibiotic therapy
C) A sign of insufficient milk supply
, D) An indication to discontinue breastfeeding
Correct Answer: Physiological engorgement as milk production transitions
Rationale: On days 2–4, the breasts become fuller, warm, and tender as milk transitions from colostrum
to mature milk. This normal engorgement is relieved by frequent feeding. Mastitis presents with
unilateral redness, fever, and malaise.
6. Which of the following is the best technique for the nurse to teach Daanis to help her newborn latch
onto the breast?
A) Hold the breast with the hand in a scissor grip near the areola
B) Gently touch the baby’s lips with the nipple and wait for a wide-open mouth before bringing the baby
to the breast
C) Insert the nipple into the baby’s mouth while the baby is sleeping
D) Press on the baby’s chin to force the mouth open
Correct Answer: Gently touch the baby’s lips with the nipple and wait for a wide-open mouth before
bringing the baby to the breast
Rationale: The baby should open wide, tongue down, and latch onto the areola, not just the nipple. The
nurse teaches the mother to wait for a gaping mouth and then quickly bring the infant to the breast to
ensure a deep, comfortable latch.
7. The nurse notes that Daanis’s newborn has a bluish discoloration of the hands and feet 2 hours after
birth. The trunk is pink. The nurse documents this as
A) Central cyanosis requiring oxygen
B) Pathologic jaundice
C) Acrocyanosis, a normal newborn finding
D) Cold stress and should place the infant under a radiant warmer
Correct Answer: Acrocyanosis, a normal newborn finding
(Daanis LaFontaine) | 100% Score | 2026
Updated
1. Which of the following is the priority nursing assessment immediately after an uncomplicated vaginal
delivery?
A) Palpate the fundus for firmness, location, and uterine tone
B) Inspect the perineum for edema
C) Obtain a full set of vital signs
D) Assess the breasts for engorgement
Correct Answer: Palpate the fundus for firmness, location, and uterine tone
Rationale: Early postpartum hemorrhage most often results from uterine atony. Assessing the fundus
confirms the uterus is contracted and midline, which compresses bleeding vessels. Vital signs and
perineal inspection are important but secondary to ensuring uterine hemostasis.
2. The nurse is caring for Daanis LaFontaine, who reports moderate perineal pain after a spontaneous
vaginal delivery with a second-degree laceration. Which nonpharmacologic measure should the nurse
offer first?
A) Suggest a warm sitz bath immediately
B) Apply an ice pack to the perineum for the first 24 hours
C) Administer a prescribed oral opioid
D) Place a donut cushion under the client
Correct Answer: Apply an ice pack to the perineum for the first 24 hours
Rationale: Cold therapy constricts blood vessels, reduces edema, and provides analgesia during the
initial 24 hours after delivery. Heat and sitz baths are introduced after 24 hours. Oral opioids require an
order and are not a nonpharmacologic measure.
,3. A postpartum client’s fundus is palpated two fingerbreadths above the umbilicus and deviated to the
right. The nurse should first
A) Massage the fundus vigorously
B) Administer oxytocin intravenously
C) Assist the client to empty her bladder
D) Notify the health care provider immediately
Correct Answer: Assist the client to empty her bladder
Rationale: A full bladder displaces the uterus upward and laterally, interfering with contraction.
Emptying the bladder often returns the fundus to midline at or below the umbilicus. Fundal massage
may follow if the uterus remains boggy.
4. During a home visit, the nurse instructs Daanis to monitor her lochia. Which description indicates she
should contact her provider?
A) Lochia rubra for the first 3 days
B) Lochia serosa from day 4 to day 10
C) Lochia alba from day 10 to week 6
D) A sudden increase in bright red bleeding after lochia has lightened
Correct Answer: A sudden increase in bright red bleeding after lochia has lightened
Rationale: Return to heavy, bright red bleeding (lochia rubra) after it has transitioned to serosa or alba
suggests late postpartum hemorrhage, often from retained placental fragments or infection. This
requires immediate evaluation.
5. The nurse is assessing Daanis LaFontaine’s breasts on postpartum day 2. The client reports mild
tenderness and the breasts are warm, firm, and secreting colostrum. The nurse identifies these findings
as
A) Physiological engorgement as milk production transitions
B) Mastitis requiring antibiotic therapy
C) A sign of insufficient milk supply
, D) An indication to discontinue breastfeeding
Correct Answer: Physiological engorgement as milk production transitions
Rationale: On days 2–4, the breasts become fuller, warm, and tender as milk transitions from colostrum
to mature milk. This normal engorgement is relieved by frequent feeding. Mastitis presents with
unilateral redness, fever, and malaise.
6. Which of the following is the best technique for the nurse to teach Daanis to help her newborn latch
onto the breast?
A) Hold the breast with the hand in a scissor grip near the areola
B) Gently touch the baby’s lips with the nipple and wait for a wide-open mouth before bringing the baby
to the breast
C) Insert the nipple into the baby’s mouth while the baby is sleeping
D) Press on the baby’s chin to force the mouth open
Correct Answer: Gently touch the baby’s lips with the nipple and wait for a wide-open mouth before
bringing the baby to the breast
Rationale: The baby should open wide, tongue down, and latch onto the areola, not just the nipple. The
nurse teaches the mother to wait for a gaping mouth and then quickly bring the infant to the breast to
ensure a deep, comfortable latch.
7. The nurse notes that Daanis’s newborn has a bluish discoloration of the hands and feet 2 hours after
birth. The trunk is pink. The nurse documents this as
A) Central cyanosis requiring oxygen
B) Pathologic jaundice
C) Acrocyanosis, a normal newborn finding
D) Cold stress and should place the infant under a radiant warmer
Correct Answer: Acrocyanosis, a normal newborn finding
