1. A gestational diabetic client, who delivered yesterday, is currently on the postpartum
unit. Which of the following statements is appropriate for the nurse to make at
this time?
1. “Monitor your blood glucose five times a day until your 6-week check-up.”
2. “I will teach you how to inject insulin before you are discharged.”
3. “Daily exercise will help to prevent you from becoming diabetic in the future.”
4. “Your baby should be assessed every 6 months for signs of juvenile diabetes.”
2. A client is receiving a blood transfusion after the delivery of a placenta acreta and
hysterectomy. Which of the following complaints by the client would warrant immediately
discontinuing the infusion?
1. “My lower back hurts all of a sudden.”
2. “My hands feel so cold.”
3. “I feel like my heart is beating fast.”
4. “I feel like I need to have a bowel movement.”
3. A client has just received Hemabate (carboprost) because of uterine atony not controlled
by IV oxytocin. For which of the following side effects of the medication
will the nurse monitor this patient?
1. Hyperthermia, vomiting, and diarrhea.
2. Hypotension and respiratory collapse.
3. Anasarca and fluid volume overload.
4. Palpitations, anxiety, and insomnia.
4. A client, who is 2 weeks postpartum, calls her obstetrician’s nurse and states that
she has had a whitish discharge for 1 week but today she is, “Bleeding and saturating
a pad about every 1⁄2 hour.” Which of the following is an appropriate response
by the nurse?
1. “That is normal. You are starting to menstruate again.”
2. “You should stay on complete bed rest until the bleeding subsides.”
3. “Pushing during a bowel movement may have loosened your stitches.”
4. “The physician should see you. Please come in whenever you are ready.”
5. The nurse is performing a postpartum assessment on a client who delivered 4 hours
ago. The nurse notes a firm uterus at the umbilicus with heavy lochial flow. Which
of the following nursing actions is appropriate?
1. Massage the uterus.
2. Notify the obstetrician.
3. Administer an oxytocic as ordered.
4. Assist the client to the bathroom.
6. A client has been receiving magnesium sulfate for severe preeclampsia for 12 hours.
Her reflexes are 0 and her respiratory rate is 10. Which of the following situations
could be a precipitating factor in these findings?
1. Apical heart rate 104.
2. Urinary output 240 cc/12 hr.
3. Blood pressure 160/120.
4. Temperature 100ºF.
7. A client received general anesthesia during her cesarean section 4 hours ago. Which
of the following postpartum nursing interventions is important for the nurse to
make?
1. Place the client flat in bed.
2. Assess for dependent edema.
3. Auscultate lung fields.
4. Check patellar reflexes.
8. The nurse is developing a standard care plan for the post–cesarean client. Which of
the following should the nurse plan to implement?
1. Maintain client in left lateral recumbent position.
2. Teach sitz bath use on second postoperative day.
,3. Perform active range of motion exercises until ambulating.
4. Assess central venous pressure during first postoperative day.
9. The nurse has administered Benadryl (diphenhydramine) to a post–cesarean client
who is experiencing side effects from the parenteral morphine sulfate that was administered
30 minutes earlier. Which of the following actions should the nurse perform
following the administration of the drug?
1. Monitor the urinary output hourly.
2. Supervise while the woman holds her newborn.
3. Position the woman slightly elevated on her left side.
4. Ask any visitors to leave the room.
10. The nurse should suspect puerperal infection when a client exhibits which of the
following?
1. Temperature of 100.2ºF.
2. White blood cell count of 14,500 cells/mm 3.
3. Diaphoresis during the night.
4. Malodorous lochial discharge.
11. A rubella nonimmune, breastfeeding client has just received the rubella vaccine.
Which of the following side effects should the nurse warn the client about?
1. The baby may develop a rash a week after the shot.
2. The baby may temporarily reject the breast milk.
3. The mother’s milk supply may decrease precipitously.
4. The mother’s joints may become painful and stif.
12. The nurse should expect to observe which behavior in a 3-week multigravid postpartum
client with postpartum depression?
1. Feelings of infanticide.
2. Difficulty with breastfeeding latch.
3. Feelings of failure as a mother.
4. Concerns about sibling jealousy.
13. Which symptom would the nurse expect to observe in a postpartum client with a
vaginal hematoma?
1. Pain.
2. Bleeding.
3. Warmth.
4. Redness.
14. A breastfeeding woman calls the pediatric nurse with the following complaint: “I
woke up this morning with a terrible cold. I don’t want my baby to get sick. Which
kind of formula should I give the baby until I get better?” Which of the following
replies by the nurse is appropriate at this time?
1. “Any formula brand is satisfactory, but it is essential that it be mixed with water
that has been boiled for at least 5 minutes.”
2. “Don’t forget to pump your breasts every 3 hours while you are feeding the
baby the prescribed formula.”
3. “The best way to keep your baby from getting sick is for you to keep
breastfeeding
him rather than switching him to formula.”
4. “In addition to feeding the baby formula, you should wear a surgical face mask
when you are around him.”
15. A woman, who wishes to breastfeed, advises the nurse that she had a breast reduction
one year earlier. Which of the following responses by the nurse is appropriate?
1. Advise the woman that unfortunately she will be unable to breastfeed.
2. Examine the woman’s breasts to see where the incision was placed.
3. Monitor the baby’s daily weights for excessive weight loss.
4. Inform the woman that reduction surgery rarely affects milk transfer.
16. The nurse is caring for a postoperative cesarean client. The woman is obese and is
,an insulin-dependent diabetic. For which of the following complications should the
nurse carefully monitor this client?
1. Ineffective lactogenesis.
2. Dysfunctional parenting.
3. Wound dehiscence.
4. Projectile vomiting.
17. A nurse who is called to a client’s room notes that the client’s cesarean incision has
separated. Which of the following actions is the highest priority for the nurse to
perform?
1. Cover the wound with sterile wet dressings.
2. Notify the surgeon.
3. Elevate the head of the client’s bed slightly.
4. Flex the client’s knees.
18. The nurse notes the following vital signs of a postoperative cesarean client during
the immediate postpartum period: 100.0ºF, P 68, R 12, BP 130/80. Which of the
following is a correct interpretation of the findings?
1. Temperature is elevated, a sign of infection.
2. Pulse is too low, a sign of vagal pathology.
3. Respirations are too low, a sign of medication toxicity.
4. Blood pressure is elevated, a sign of preeclampsia.
19. The nurse is discharging four Rh-negative clients from the maternity unit. The
nurse knows that further teaching is needed when the client who had which of the
following deliveries asks why she has not received her RhoGAM?
1. Abortion at 10 weeks’ gestation.
2. Fetal demise at 24 weeks’ gestation.
3. Birth of Rh-negative twins at 35 weeks’ gestation.
4. Delivery of a 40-week-gestation Rh-positive baby.
20. In which of the following situations should a nurse report a possible deep vein
thrombosis (DVT) even when the woman has a negative Homan’s sign?
1. The woman complains of numbness in the toes and heel of one foot.
2. The woman has cramping pain in a calf that is relieved when the foot is
dorsiflexed.
3. One of the woman’s calves is swollen, red, and warm to the touch.
4. The veins in the ankle of one of the woman’s legs are spider-like and purple
21. A woman, 26 weeks’ gestation, has just delivered a fetal demise. Which of the following
nursing actions is appropriate at this time?
1. Remind the mother that she will be able to have another baby in the future.
2. Dress the baby in a tee shirt and swaddle the baby in a receiving blanket.
3. Ask the woman if she would like the doctor to prescribe a sedative for her.
4. Remove the baby from the delivery room as soon as possible.
22. A client, G1P0000, is PP1 from a normal spontaneous delivery of a baby boy,
Apgar 5/6. Because the client exhibited addictive behaviors, a toxicology assessment
was performed; the results were positive for alcohol and cocaine. Which of the following
interventions is appropriate for this postpartum client?
1. Strongly advise the client to breastfeed her baby.
2. Perform hourly incentive spirometer respiratory assessments.
3. Suggest that the nursery nurse feed the baby in the nursery.
4. Provide the client with supervised instruction on baby care skills.
23. A client is 10 minutes postpartum from a forceps delivery of a 4500-gram Down
syndrome neonate over a right mediolateral episiotomy. The client is at risk for
each of the following nursing diagnoses. Which of the diagnoses is highest priority
at this time?
1. Ineffective breastfeeding.
2. Fluid volume deficit.
, 3. Infection.
4. Pain.
24. A client is postpartum 24 hours from a spontaneous vaginal delivery with rupture of
membranes for 42 hours. Which of the following signs/symptoms should the nurse
report to the client’s health care practitioner?
1. Foul-smelling lochia.
2. Engorged breasts.
3. Cracked nipples.
4. Cluster of hemorrhoids.
25. A client is 36 hours post–cesarean section. Which of the following assessments
would indicate that the client may have a paralytic ileus?
1. Abdominal striae.
2. Oliguria.
3. Omphalocele.
4. Absent bowel sounds.
26. A client, 1 day postpartum (PP), is being monitored carefully after a significant
postpartum hemorrhage. Which of the following should the nurse report to the obstetrician?
1. Urine output 200 mL for last 8 hours.
2. Weight decrease of 2 pounds since delivery.
3. Drop in hematocrit of 2% since admission.
4. Pulse rate of 68 beats per minute.
27. A nurse is working on the postpartum unit. Which of the following patients should
the nurse assess first?
1. PP1 from vaginal delivery complains of burning on urination.
2. PP1 from forceps delivery with blood loss of 500 mL at time of delivery.
3. PP3 from vacuum delivery with hemoglobin of 7.2 g/dL.
4. PO3 from cesarean delivery complains of firm and painful breasts
28. A nurse has administered Methergine (methylergonovine) 0.2 mg po to a grand
multipara who delivered vaginally 30 minutes earlier. Which of the following outcomes
indicates that the medication is effective?
1. Blood pressure 120/80.
2. Pulse rate 80 bpm and regular.
3. Fundus firm at umbilicus.
4. Increase in prothrombin time.
29. A nurse on the postpartum unit is caring for two postoperative cesarean clients.
One client had spinal anesthesia for the delivery while the other client had an
epidural. Which of the following complications will the nurse monitor the spinal
client for that the epidural client is much less high risk for?
1. Pruritus.
2. Nausea.
3. Postural headache.
4. Respiratory depression.
30. A postpartum woman has been diagnosed with postpartum psychosis. Which of the
following signs/symptoms would the client exhibit?
1. Hallucinations.
2. Polyphagia.
3. Induced vomiting.
4. Weepy sadness.
31. The nurse is providing discharge counseling to a woman who is breastfeeding her
baby. What should the nurse advise the woman to do if she should palpate tender,
hard nodules in her breasts?
1. Gently massage the areas toward the nipple especially during feedings.
2. Apply ice to the areas between feedings.
3. Bottlefeed for the next twenty-four hours.
unit. Which of the following statements is appropriate for the nurse to make at
this time?
1. “Monitor your blood glucose five times a day until your 6-week check-up.”
2. “I will teach you how to inject insulin before you are discharged.”
3. “Daily exercise will help to prevent you from becoming diabetic in the future.”
4. “Your baby should be assessed every 6 months for signs of juvenile diabetes.”
2. A client is receiving a blood transfusion after the delivery of a placenta acreta and
hysterectomy. Which of the following complaints by the client would warrant immediately
discontinuing the infusion?
1. “My lower back hurts all of a sudden.”
2. “My hands feel so cold.”
3. “I feel like my heart is beating fast.”
4. “I feel like I need to have a bowel movement.”
3. A client has just received Hemabate (carboprost) because of uterine atony not controlled
by IV oxytocin. For which of the following side effects of the medication
will the nurse monitor this patient?
1. Hyperthermia, vomiting, and diarrhea.
2. Hypotension and respiratory collapse.
3. Anasarca and fluid volume overload.
4. Palpitations, anxiety, and insomnia.
4. A client, who is 2 weeks postpartum, calls her obstetrician’s nurse and states that
she has had a whitish discharge for 1 week but today she is, “Bleeding and saturating
a pad about every 1⁄2 hour.” Which of the following is an appropriate response
by the nurse?
1. “That is normal. You are starting to menstruate again.”
2. “You should stay on complete bed rest until the bleeding subsides.”
3. “Pushing during a bowel movement may have loosened your stitches.”
4. “The physician should see you. Please come in whenever you are ready.”
5. The nurse is performing a postpartum assessment on a client who delivered 4 hours
ago. The nurse notes a firm uterus at the umbilicus with heavy lochial flow. Which
of the following nursing actions is appropriate?
1. Massage the uterus.
2. Notify the obstetrician.
3. Administer an oxytocic as ordered.
4. Assist the client to the bathroom.
6. A client has been receiving magnesium sulfate for severe preeclampsia for 12 hours.
Her reflexes are 0 and her respiratory rate is 10. Which of the following situations
could be a precipitating factor in these findings?
1. Apical heart rate 104.
2. Urinary output 240 cc/12 hr.
3. Blood pressure 160/120.
4. Temperature 100ºF.
7. A client received general anesthesia during her cesarean section 4 hours ago. Which
of the following postpartum nursing interventions is important for the nurse to
make?
1. Place the client flat in bed.
2. Assess for dependent edema.
3. Auscultate lung fields.
4. Check patellar reflexes.
8. The nurse is developing a standard care plan for the post–cesarean client. Which of
the following should the nurse plan to implement?
1. Maintain client in left lateral recumbent position.
2. Teach sitz bath use on second postoperative day.
,3. Perform active range of motion exercises until ambulating.
4. Assess central venous pressure during first postoperative day.
9. The nurse has administered Benadryl (diphenhydramine) to a post–cesarean client
who is experiencing side effects from the parenteral morphine sulfate that was administered
30 minutes earlier. Which of the following actions should the nurse perform
following the administration of the drug?
1. Monitor the urinary output hourly.
2. Supervise while the woman holds her newborn.
3. Position the woman slightly elevated on her left side.
4. Ask any visitors to leave the room.
10. The nurse should suspect puerperal infection when a client exhibits which of the
following?
1. Temperature of 100.2ºF.
2. White blood cell count of 14,500 cells/mm 3.
3. Diaphoresis during the night.
4. Malodorous lochial discharge.
11. A rubella nonimmune, breastfeeding client has just received the rubella vaccine.
Which of the following side effects should the nurse warn the client about?
1. The baby may develop a rash a week after the shot.
2. The baby may temporarily reject the breast milk.
3. The mother’s milk supply may decrease precipitously.
4. The mother’s joints may become painful and stif.
12. The nurse should expect to observe which behavior in a 3-week multigravid postpartum
client with postpartum depression?
1. Feelings of infanticide.
2. Difficulty with breastfeeding latch.
3. Feelings of failure as a mother.
4. Concerns about sibling jealousy.
13. Which symptom would the nurse expect to observe in a postpartum client with a
vaginal hematoma?
1. Pain.
2. Bleeding.
3. Warmth.
4. Redness.
14. A breastfeeding woman calls the pediatric nurse with the following complaint: “I
woke up this morning with a terrible cold. I don’t want my baby to get sick. Which
kind of formula should I give the baby until I get better?” Which of the following
replies by the nurse is appropriate at this time?
1. “Any formula brand is satisfactory, but it is essential that it be mixed with water
that has been boiled for at least 5 minutes.”
2. “Don’t forget to pump your breasts every 3 hours while you are feeding the
baby the prescribed formula.”
3. “The best way to keep your baby from getting sick is for you to keep
breastfeeding
him rather than switching him to formula.”
4. “In addition to feeding the baby formula, you should wear a surgical face mask
when you are around him.”
15. A woman, who wishes to breastfeed, advises the nurse that she had a breast reduction
one year earlier. Which of the following responses by the nurse is appropriate?
1. Advise the woman that unfortunately she will be unable to breastfeed.
2. Examine the woman’s breasts to see where the incision was placed.
3. Monitor the baby’s daily weights for excessive weight loss.
4. Inform the woman that reduction surgery rarely affects milk transfer.
16. The nurse is caring for a postoperative cesarean client. The woman is obese and is
,an insulin-dependent diabetic. For which of the following complications should the
nurse carefully monitor this client?
1. Ineffective lactogenesis.
2. Dysfunctional parenting.
3. Wound dehiscence.
4. Projectile vomiting.
17. A nurse who is called to a client’s room notes that the client’s cesarean incision has
separated. Which of the following actions is the highest priority for the nurse to
perform?
1. Cover the wound with sterile wet dressings.
2. Notify the surgeon.
3. Elevate the head of the client’s bed slightly.
4. Flex the client’s knees.
18. The nurse notes the following vital signs of a postoperative cesarean client during
the immediate postpartum period: 100.0ºF, P 68, R 12, BP 130/80. Which of the
following is a correct interpretation of the findings?
1. Temperature is elevated, a sign of infection.
2. Pulse is too low, a sign of vagal pathology.
3. Respirations are too low, a sign of medication toxicity.
4. Blood pressure is elevated, a sign of preeclampsia.
19. The nurse is discharging four Rh-negative clients from the maternity unit. The
nurse knows that further teaching is needed when the client who had which of the
following deliveries asks why she has not received her RhoGAM?
1. Abortion at 10 weeks’ gestation.
2. Fetal demise at 24 weeks’ gestation.
3. Birth of Rh-negative twins at 35 weeks’ gestation.
4. Delivery of a 40-week-gestation Rh-positive baby.
20. In which of the following situations should a nurse report a possible deep vein
thrombosis (DVT) even when the woman has a negative Homan’s sign?
1. The woman complains of numbness in the toes and heel of one foot.
2. The woman has cramping pain in a calf that is relieved when the foot is
dorsiflexed.
3. One of the woman’s calves is swollen, red, and warm to the touch.
4. The veins in the ankle of one of the woman’s legs are spider-like and purple
21. A woman, 26 weeks’ gestation, has just delivered a fetal demise. Which of the following
nursing actions is appropriate at this time?
1. Remind the mother that she will be able to have another baby in the future.
2. Dress the baby in a tee shirt and swaddle the baby in a receiving blanket.
3. Ask the woman if she would like the doctor to prescribe a sedative for her.
4. Remove the baby from the delivery room as soon as possible.
22. A client, G1P0000, is PP1 from a normal spontaneous delivery of a baby boy,
Apgar 5/6. Because the client exhibited addictive behaviors, a toxicology assessment
was performed; the results were positive for alcohol and cocaine. Which of the following
interventions is appropriate for this postpartum client?
1. Strongly advise the client to breastfeed her baby.
2. Perform hourly incentive spirometer respiratory assessments.
3. Suggest that the nursery nurse feed the baby in the nursery.
4. Provide the client with supervised instruction on baby care skills.
23. A client is 10 minutes postpartum from a forceps delivery of a 4500-gram Down
syndrome neonate over a right mediolateral episiotomy. The client is at risk for
each of the following nursing diagnoses. Which of the diagnoses is highest priority
at this time?
1. Ineffective breastfeeding.
2. Fluid volume deficit.
, 3. Infection.
4. Pain.
24. A client is postpartum 24 hours from a spontaneous vaginal delivery with rupture of
membranes for 42 hours. Which of the following signs/symptoms should the nurse
report to the client’s health care practitioner?
1. Foul-smelling lochia.
2. Engorged breasts.
3. Cracked nipples.
4. Cluster of hemorrhoids.
25. A client is 36 hours post–cesarean section. Which of the following assessments
would indicate that the client may have a paralytic ileus?
1. Abdominal striae.
2. Oliguria.
3. Omphalocele.
4. Absent bowel sounds.
26. A client, 1 day postpartum (PP), is being monitored carefully after a significant
postpartum hemorrhage. Which of the following should the nurse report to the obstetrician?
1. Urine output 200 mL for last 8 hours.
2. Weight decrease of 2 pounds since delivery.
3. Drop in hematocrit of 2% since admission.
4. Pulse rate of 68 beats per minute.
27. A nurse is working on the postpartum unit. Which of the following patients should
the nurse assess first?
1. PP1 from vaginal delivery complains of burning on urination.
2. PP1 from forceps delivery with blood loss of 500 mL at time of delivery.
3. PP3 from vacuum delivery with hemoglobin of 7.2 g/dL.
4. PO3 from cesarean delivery complains of firm and painful breasts
28. A nurse has administered Methergine (methylergonovine) 0.2 mg po to a grand
multipara who delivered vaginally 30 minutes earlier. Which of the following outcomes
indicates that the medication is effective?
1. Blood pressure 120/80.
2. Pulse rate 80 bpm and regular.
3. Fundus firm at umbilicus.
4. Increase in prothrombin time.
29. A nurse on the postpartum unit is caring for two postoperative cesarean clients.
One client had spinal anesthesia for the delivery while the other client had an
epidural. Which of the following complications will the nurse monitor the spinal
client for that the epidural client is much less high risk for?
1. Pruritus.
2. Nausea.
3. Postural headache.
4. Respiratory depression.
30. A postpartum woman has been diagnosed with postpartum psychosis. Which of the
following signs/symptoms would the client exhibit?
1. Hallucinations.
2. Polyphagia.
3. Induced vomiting.
4. Weepy sadness.
31. The nurse is providing discharge counseling to a woman who is breastfeeding her
baby. What should the nurse advise the woman to do if she should palpate tender,
hard nodules in her breasts?
1. Gently massage the areas toward the nipple especially during feedings.
2. Apply ice to the areas between feedings.
3. Bottlefeed for the next twenty-four hours.
