Maternity Nursing: Postpartum
NCLEX Practice Questions #8 | 55
Questions
1. Question
A postpartum nurse is preparing to care for a woman who has
just delivered a healthy newborn infant. In the immediate
postpartum period, the nurse plans to take the woman’s vital
signs:
o A. Every 30 minutes during the first hour and then every
hour for the next two hours.
o B. Every 15 minutes during the first hour and then
every 30 minutes for the next two hours.
o C. Every hour for the first 2 hours and then every 4
hours.
o D. Every 5 minutes for the first 30 minutes and then
every hour for the next 4 hours.
Incorrect
Correct Answer: B. Every 15 minutes during the first hour
and then every 30 minutes for the next two hours.
The initial or acute period involves the first 6–12 hours
postpartum. This is a time of rapid change with a potential for
immediate crises such as postpartum hemorrhage, uterine
inversion, amniotic fluid embolism, and eclampsia.
Option A: The second phase is the subacute
postpartum period, which lasts 2–6 weeks. During this
phase, the body is undergoing major changes in terms
of hemodynamics, genitourinary recovery,
metabolism, and emotional status. Nonetheless, the
changes are less rapid than in the acute postpartum
phase and the patient is generally capable of self-
identifying problems. These may run the gamut from
ordinary concerns about perineal discomfort to
, peripartum cardiomyopathy or severe postpartum
depression.
Option C: The third phase is the delayed postpartum
period, which can last up to 6 months. Changes during
this phase are extremely gradual, and pathology is
rare. This period is used to make sure the mother is
stable and to educate her in the care of her baby
(especially the first-time mother). While still in the
hospital, the mother is monitored for blood loss, signs
of infection, abnormal blood pressure, contraction of
the uterus, and ability to void. There is also attention
to Rh compatibility, maternal immunization statuses,
and breastfeeding. This is the time of restoration of
muscle tone and connective tissue to the prepregnant
state. Although change is subtle during this phase, it
behooves caregivers to remember that a woman?s
body is nonetheless not fully restored to prepregnant
physiology until about 6 months post-delivery.
Option D: The immediate postpartum period most
often occurs in the hospital setting, where the majority
of women remain for approximately 2 days after a
vaginal delivery and 3-4 days after a cesarean
delivery. During this time, women are recovering from
their delivery and are beginning to care for the
newborn.
2. 2. Question
A postpartum nurse is taking the vital signs of a woman who
delivered a healthy newborn infant 4 hours ago. The nurse notes
that the mother’s temperature is 100.2°F. Which of the following
actions would be most appropriate?
A. Retake the temperature in 15 minutes.
B. Notify the physician.
C. Document the findings.
D. Increase hydration by encouraging oral fluids
Incorrect
, Correct Answer: D. Increase hydration by encouraging
oral fluids.
The mother’s temperature may be taken every 4 hours while she
is awake. Temperatures up to 100.4 F (38 C) in the first 24 hours
after birth are often related to the dehydrating effects of labor.
The most appropriate action is to increase hydration by
encouraging oral fluids, which should bring the temperature to a
normal reading.
Option A: A focused physical examination is
important and should include vital signs, an
examination of the respiratory system, breasts,
abdomen, perineum, and lower extremities. A patient
with endometritis typically has a fever of 38°C or
greater, tachycardia, and fundal tenderness.
Option B: The new mother should be given discharge
instructions and expectations/precautions to consider
once leaving the hospital. The most important
information is who and where to call if she has
problems or questions. She also needs details about
resuming her normal activity. Instructions vary,
depending on whether the mother has had a vaginal
or a cesarean delivery and any comorbidities that may
have been part of her care.
Option C: Although the nurse would document the
findings, the most appropriate action would be to
increase the hydration. The woman who has had a
vaginal delivery may resume all physical activity,
including using stairs, riding or driving in a car, and
performing muscle-toning exercises, as long as she
experiences no limiting pain or discomfort. The key
counseling is to progressively resume normal activity
while being mindful of the common fatigue and
exhaustion experienced while caring for a newborn.
3. 3. Question
The nurse is assessing a client who is 6 hours PP after delivering
a full-term healthy infant. The client complains to the nurse of
feelings of faintness and dizziness. Which of the following nursing
actions would be most appropriate?
A. Obtain hemoglobin and hematocrit levels.
, B. Instruct the mother to request help when
getting out of bed.
C. Elevate the mother’s legs.
D. Inform the nursery room nurse to avoid bringing the
newborn infant to the mother until the feelings of
lightheadedness and dizziness have subsided.
Incorrect
Correct Answer: B. Instruct the mother to request help
when getting out of bed.
Orthostatic hypotension may be evident during the first 8 hours
after birth. Feelings of faintness or dizziness are signs that should
caution the nurse to be aware of the client’s safety. The nurse
should advise the mother to get help the first few times the
mother gets out of bed.
Option A: Obtaining an H/H requires a physician’s
order. This is a blood test that checks the percent of
the blood (called whole blood) that’s made up of red
blood cells. Bleeding can cause a low hematocrit.
Option C: With PPH, the client can lose much more
blood, which is what makes it a dangerous condition.
PPH can cause a severe drop in blood pressure. If not
treated quickly, this can lead to shock and death.
Shock is when the body organs don’t get enough blood
flow.
Option D: Postpartum hemorrhage (also called PPH)
is when a woman has heavy bleeding after giving
birth. It’s a serious but rare condition. It usually
happens within 1 day of giving birth, but it can happen
up to 12 weeks after having a baby. About 1 to 5 in
100 women who have a baby (1 to 5 percent) have
PPH.
4. 4. Question
A nurse is preparing to perform a fundal assessment on a
postpartum client. The initial nursing action in performing this
assessment is which of the following?
A. Ask the client to turn on her side.
NCLEX Practice Questions #8 | 55
Questions
1. Question
A postpartum nurse is preparing to care for a woman who has
just delivered a healthy newborn infant. In the immediate
postpartum period, the nurse plans to take the woman’s vital
signs:
o A. Every 30 minutes during the first hour and then every
hour for the next two hours.
o B. Every 15 minutes during the first hour and then
every 30 minutes for the next two hours.
o C. Every hour for the first 2 hours and then every 4
hours.
o D. Every 5 minutes for the first 30 minutes and then
every hour for the next 4 hours.
Incorrect
Correct Answer: B. Every 15 minutes during the first hour
and then every 30 minutes for the next two hours.
The initial or acute period involves the first 6–12 hours
postpartum. This is a time of rapid change with a potential for
immediate crises such as postpartum hemorrhage, uterine
inversion, amniotic fluid embolism, and eclampsia.
Option A: The second phase is the subacute
postpartum period, which lasts 2–6 weeks. During this
phase, the body is undergoing major changes in terms
of hemodynamics, genitourinary recovery,
metabolism, and emotional status. Nonetheless, the
changes are less rapid than in the acute postpartum
phase and the patient is generally capable of self-
identifying problems. These may run the gamut from
ordinary concerns about perineal discomfort to
, peripartum cardiomyopathy or severe postpartum
depression.
Option C: The third phase is the delayed postpartum
period, which can last up to 6 months. Changes during
this phase are extremely gradual, and pathology is
rare. This period is used to make sure the mother is
stable and to educate her in the care of her baby
(especially the first-time mother). While still in the
hospital, the mother is monitored for blood loss, signs
of infection, abnormal blood pressure, contraction of
the uterus, and ability to void. There is also attention
to Rh compatibility, maternal immunization statuses,
and breastfeeding. This is the time of restoration of
muscle tone and connective tissue to the prepregnant
state. Although change is subtle during this phase, it
behooves caregivers to remember that a woman?s
body is nonetheless not fully restored to prepregnant
physiology until about 6 months post-delivery.
Option D: The immediate postpartum period most
often occurs in the hospital setting, where the majority
of women remain for approximately 2 days after a
vaginal delivery and 3-4 days after a cesarean
delivery. During this time, women are recovering from
their delivery and are beginning to care for the
newborn.
2. 2. Question
A postpartum nurse is taking the vital signs of a woman who
delivered a healthy newborn infant 4 hours ago. The nurse notes
that the mother’s temperature is 100.2°F. Which of the following
actions would be most appropriate?
A. Retake the temperature in 15 minutes.
B. Notify the physician.
C. Document the findings.
D. Increase hydration by encouraging oral fluids
Incorrect
, Correct Answer: D. Increase hydration by encouraging
oral fluids.
The mother’s temperature may be taken every 4 hours while she
is awake. Temperatures up to 100.4 F (38 C) in the first 24 hours
after birth are often related to the dehydrating effects of labor.
The most appropriate action is to increase hydration by
encouraging oral fluids, which should bring the temperature to a
normal reading.
Option A: A focused physical examination is
important and should include vital signs, an
examination of the respiratory system, breasts,
abdomen, perineum, and lower extremities. A patient
with endometritis typically has a fever of 38°C or
greater, tachycardia, and fundal tenderness.
Option B: The new mother should be given discharge
instructions and expectations/precautions to consider
once leaving the hospital. The most important
information is who and where to call if she has
problems or questions. She also needs details about
resuming her normal activity. Instructions vary,
depending on whether the mother has had a vaginal
or a cesarean delivery and any comorbidities that may
have been part of her care.
Option C: Although the nurse would document the
findings, the most appropriate action would be to
increase the hydration. The woman who has had a
vaginal delivery may resume all physical activity,
including using stairs, riding or driving in a car, and
performing muscle-toning exercises, as long as she
experiences no limiting pain or discomfort. The key
counseling is to progressively resume normal activity
while being mindful of the common fatigue and
exhaustion experienced while caring for a newborn.
3. 3. Question
The nurse is assessing a client who is 6 hours PP after delivering
a full-term healthy infant. The client complains to the nurse of
feelings of faintness and dizziness. Which of the following nursing
actions would be most appropriate?
A. Obtain hemoglobin and hematocrit levels.
, B. Instruct the mother to request help when
getting out of bed.
C. Elevate the mother’s legs.
D. Inform the nursery room nurse to avoid bringing the
newborn infant to the mother until the feelings of
lightheadedness and dizziness have subsided.
Incorrect
Correct Answer: B. Instruct the mother to request help
when getting out of bed.
Orthostatic hypotension may be evident during the first 8 hours
after birth. Feelings of faintness or dizziness are signs that should
caution the nurse to be aware of the client’s safety. The nurse
should advise the mother to get help the first few times the
mother gets out of bed.
Option A: Obtaining an H/H requires a physician’s
order. This is a blood test that checks the percent of
the blood (called whole blood) that’s made up of red
blood cells. Bleeding can cause a low hematocrit.
Option C: With PPH, the client can lose much more
blood, which is what makes it a dangerous condition.
PPH can cause a severe drop in blood pressure. If not
treated quickly, this can lead to shock and death.
Shock is when the body organs don’t get enough blood
flow.
Option D: Postpartum hemorrhage (also called PPH)
is when a woman has heavy bleeding after giving
birth. It’s a serious but rare condition. It usually
happens within 1 day of giving birth, but it can happen
up to 12 weeks after having a baby. About 1 to 5 in
100 women who have a baby (1 to 5 percent) have
PPH.
4. 4. Question
A nurse is preparing to perform a fundal assessment on a
postpartum client. The initial nursing action in performing this
assessment is which of the following?
A. Ask the client to turn on her side.
