NURS CM EXAM 3 QUESTIONS WITH ANSWERS CHAPTER 28 to 35 –
POSTPARTUM ADAPTATION AND NURSING ASSESSMENT LATEST
UPDATE 2022
1) The nurse is preparing to assess assigned clients on a postpartum unit. Which client
should be seen first?
1. Multipara, second day postcesarean, moderate lochia serosa
2. Primipara, day of delivery, fundus firm 2 cm above umbilicus
3. Multipara, first postpartum day, 4 cm diastasis recti abdominis
4. Primipara, first postpartum day, hypoactive bowel sounds all
quadrants Answer: 2
Explanation:
1. This client is not experiencing any unexpected findings.
2. This client is the top priority. The fundus should not be positioned above the umbilicus
after delivery. This high location could indicate an overdistended bladder or uterine atony
and excessive bleeding.
3. This finding is normal, especially in a multiparous client.
4. Bowel sounds are often decreased after delivery.
2) What amount of weight loss, in pounds, should the nurse expect in an average postpartum
client?
1. 5 to 8
2. 10 to 12
3. 12 to 15
4. 15 to 20
Answer: 2
Explanation:
1. A loss of 5 to 8 lb might occur after a preterm birth.
2. A loss of 10 to 12 lb is the usual initial weight loss. This weight is lost with the birth of
the infant and the expulsion of the placenta and the amniotic fluid.
3. A loss of 12 to 15 lb does not match the usual weight of placenta, amniotic fluid, and
full- term infant weight.
4. A loss of 15 to 20 lb might occur after a multiple birth.
3) What should the nurse assess to determine healing of the uterus at the placental site?
1. Laboratory values
2. Uterine size
3. Blood pressure
4. Type, amount, and consistency of
lochia Answer: 4
Explanation:
1. Laboratory values are too vague, since the actual values are not identified.
2. Uterine size alone is not enough to assess the placental site.
NURS CM EXAM 3 QUESTIONS WITH ANSWERS CHAPTER 28 to 35 –
POSTPARTUM ADAPTATION AND NURSING ASSESSMENT LATEST
UPDATE 2022
, NURS CM EXAM 3 QUESTIONS WITH ANSWERS CHAPTER 28 to 35 –
POSTPARTUM ADAPTATION AND NURSING ASSESSMENT LATEST
UPDATE 2022
3. Blood pressure varies slightly in the normal postpartum client and would not affect
the placental site.
4. Type, amount, and consistency of lochia determine the stage of healing of the placental
site, which occurs by a process of exfoliation.
4) On the first postpartum day, the nurse teaches a client about breastfeeding. Two hours
later, the mother seems to remember very little of the teaching. What should the nurse
identify as the reason for the client’s memory lapse?
1. Epidural anesthesia
2. The taking-in phase
3. The taking-hold phase
4. Postpartum
hemorrhage Answer: 2
Explanation:
1. Epidural anesthesia is a pharmacologic approach to pain control.
2. The taking-in phase, which occurs during the first day or two following birth, is
characterized by a passive and dependent affect. The mother also might be in need of
food and rest.
3. The taking-hold phase occurs by the second or third day, when the mother is ready
to resume control of life and is open to teaching.
4. Postpartum hemorrhage is a serious complication and will need medical intervention.
5) The nurse is observing a graduate nurse’s assessment of a postpartum client. For
which action by the graduate nurse should the nurse intervene?
1. Asking the client to void before applying clean gloves
2. Instructing visitors to leave the room prior to beginning the assessment
3. Requesting the client lie flat in bed with the head on a pillow prior to the fundal assessment
4. Discussing the effectiveness of comfort measures while performing the perineal
assessment Answer: 2
Explanation:
1. Voiding prior to the assessment helps ensure comfort; clean gloves prevent exposure
to body fluids.
2. The nurse should allow the client to choose whether visitors leave or remain in the
room during the assessment.
3. The supine position prevents a falsely high assessment of fundal height.
4. The assessment provides an excellent opportunity for teaching about good
healthcare practices in both the short and long term, including comfort measures.
6) In which order should the nurse conduct the examination of a postpartum client?
1. L–lochia
2. B–bowel
NURS CM EXAM 3 QUESTIONS WITH ANSWERS CHAPTER 28 to 35 –
POSTPARTUM ADAPTATION AND NURSING ASSESSMENT LATEST
UPDATE 2022
, NURS CM EXAM 3 QUESTIONS WITH ANSWERS CHAPTER 28 to 35 –
POSTPARTUM ADAPTATION AND NURSING ASSESSMENT LATEST
UPDATE 2022
3. B–breast
4. U–uterus
5. B–bladder
6. E–emotional
7. H–Homans/hemorrhoids
8. E–episiotomy/laceration/edema
Answer: 3, 4, 5, 2, 1, 8, 7, 6
Explanation:
1. An easy way to remember the components specific to the postpartum examination is to
remember the term BUBBLEHE: B–breast, U–uterus, B–bladder, B–bowel, L–lochia,
E–episiotomy/laceration/edema, H–Homans/hemorrhoids, E–emotional.
2. An easy way to remember the components specific to the postpartum examination is to
remember the term BUBBLEHE: B–breast, U–uterus, B–bladder, B–bowel, L–lochia,
E–episiotomy/laceration/edema, H–Homans/hemorrhoids, E–emotional.
3. An easy way to remember the components specific to the postpartum examination is to
remember the term BUBBLEHE: B–breast, U–uterus, B–bladder, B–bowel, L–lochia,
E–episiotomy/laceration/edema, H–Homans/hemorrhoids, E–emotional.
4. An easy way to remember the components specific to the postpartum examination is to
remember the term BUBBLEHE: B–breast, U–uterus, B–bladder, B–bowel, L–lochia,
E–episiotomy/laceration/edema, H–Homans/hemorrhoids, E–emotional.
5. An easy way to remember the components specific to the postpartum examination is to
remember the term BUBBLEHE: B–breast, U–uterus, B–bladder, B–bowel, L–lochia,
E–episiotomy/laceration/edema, H–Homans/hemorrhoids, E–emotional.
6. An easy way to remember the components specific to the postpartum examination is to
remember the term BUBBLEHE: B–breast, U–uterus, B–bladder, B–bowel, L–lochia,
E–episiotomy/laceration/edema, H–Homans/hemorrhoids, E–emotional.
7. An easy way to remember the components specific to the postpartum examination is to
remember the term BUBBLEHE: B–breast, U–uterus, B–bladder, B–bowel, L–lochia,
E–episiotomy/laceration/edema, H–Homans/hemorrhoids, E–emotional.
8. An easy way to remember the components specific to the postpartum examination is to
remember the term BUBBLEHE: B–breast, U–uterus, B–bladder, B–bowel, L–lochia,
E–episiotomy/laceration/edema, H–Homans/hemorrhoids, E–emotional.
7) A postpartum client becomes concerned when a gush of blood occurs during the fundal
assessment. What should the nurse explain about this occurrence?
1. “Do not worry. I will make sure everything is fine.”
2. “We see this from time to time. It’s not a big deal.”
3. “Blood has pooled in the vagina while you were in bed.”
4. “The gush is an indication that your fundus is not
contracting.” Answer: 3
Explanation:
1. This response is not therapeutic because it focuses on the nurse and has a “do not
NURS CM EXAM 3 QUESTIONS WITH ANSWERS CHAPTER 28 to 35 –
POSTPARTUM ADAPTATION AND NURSING ASSESSMENT LATEST
UPDATE 2022
, NURS CM EXAM 3 QUESTIONS WITH ANSWERS CHAPTER 28 to 35 –
POSTPARTUM ADAPTATION AND NURSING ASSESSMENT LATEST
UPDATE 2022
worry” aspect that is demeaning.
2. Although a gush of blood during fundus assessment is fairly common, this response is
not therapeutic because it does not address the client’s concern.
3. Because of the angle of the vagina, lochia pools in the vagina while a woman is lying
or semisitting in bed, which leads to a gush when fundal massage is performed.
4. The fundus might be contracting well. The gush is from pooled lochia in the vagina.
8) A postpartum client is not going to breastfeed her newborn. What should the nurse include
when teaching this client about breast care?
1. The let-down reflex
2. Lactation suppression
3. The purpose of fundal massage
4. The cause of afterpains
Answer: 2
Explanation:
1. The let-down reflex is an important teaching point for breastfeeding patients.
2. It is important to teach nonbreastfeeding patients about lactation suppression after delivery.
3. The purpose of fundal massage should be addressed when assessing the uterus and
fundus, not when assessing the breasts.
4. Afterpains can be stimulated by breastfeeding. The nurse will not likely teach
a nonbreastfeeding primipara about afterpains.
9) Every time the nurse enters the client’s room, the client, who delivered 3 hours ago, asks
the nurse something else about the birth experience. What action should the nurse take?
1. Answer questions quickly and try to divert attention to other subjects.
2. Review documentation of the birth experience and discuss it with the client.
3. Contact the healthcare provider because of changes in the client’s memory.
4. Submit a referral to Social Services because of concerns about obsessive
behavior. Answer: 2
Explanation:
1. Answering questions quickly and trying to divert attention to other subjects trivializes the
questions and does not allow the client to sort out the reality from the subjective
experience.
2. Reviewing the documentation of the birth experience and discussing it with the client
helps the client integrate the experience and talk about perceptions of the labor and
delivery experience.
3. The client is not demonstrating changes in memory. The healthcare provider does not
need to be contacted.
4. Submitting a referral to Social Services because of obsessive behavior is not
appropriate. The client is demonstrating normal behavior.
NURS CM EXAM 3 QUESTIONS WITH ANSWERS CHAPTER 28 to 35 –
POSTPARTUM ADAPTATION AND NURSING ASSESSMENT LATEST
UPDATE 2022
POSTPARTUM ADAPTATION AND NURSING ASSESSMENT LATEST
UPDATE 2022
1) The nurse is preparing to assess assigned clients on a postpartum unit. Which client
should be seen first?
1. Multipara, second day postcesarean, moderate lochia serosa
2. Primipara, day of delivery, fundus firm 2 cm above umbilicus
3. Multipara, first postpartum day, 4 cm diastasis recti abdominis
4. Primipara, first postpartum day, hypoactive bowel sounds all
quadrants Answer: 2
Explanation:
1. This client is not experiencing any unexpected findings.
2. This client is the top priority. The fundus should not be positioned above the umbilicus
after delivery. This high location could indicate an overdistended bladder or uterine atony
and excessive bleeding.
3. This finding is normal, especially in a multiparous client.
4. Bowel sounds are often decreased after delivery.
2) What amount of weight loss, in pounds, should the nurse expect in an average postpartum
client?
1. 5 to 8
2. 10 to 12
3. 12 to 15
4. 15 to 20
Answer: 2
Explanation:
1. A loss of 5 to 8 lb might occur after a preterm birth.
2. A loss of 10 to 12 lb is the usual initial weight loss. This weight is lost with the birth of
the infant and the expulsion of the placenta and the amniotic fluid.
3. A loss of 12 to 15 lb does not match the usual weight of placenta, amniotic fluid, and
full- term infant weight.
4. A loss of 15 to 20 lb might occur after a multiple birth.
3) What should the nurse assess to determine healing of the uterus at the placental site?
1. Laboratory values
2. Uterine size
3. Blood pressure
4. Type, amount, and consistency of
lochia Answer: 4
Explanation:
1. Laboratory values are too vague, since the actual values are not identified.
2. Uterine size alone is not enough to assess the placental site.
NURS CM EXAM 3 QUESTIONS WITH ANSWERS CHAPTER 28 to 35 –
POSTPARTUM ADAPTATION AND NURSING ASSESSMENT LATEST
UPDATE 2022
, NURS CM EXAM 3 QUESTIONS WITH ANSWERS CHAPTER 28 to 35 –
POSTPARTUM ADAPTATION AND NURSING ASSESSMENT LATEST
UPDATE 2022
3. Blood pressure varies slightly in the normal postpartum client and would not affect
the placental site.
4. Type, amount, and consistency of lochia determine the stage of healing of the placental
site, which occurs by a process of exfoliation.
4) On the first postpartum day, the nurse teaches a client about breastfeeding. Two hours
later, the mother seems to remember very little of the teaching. What should the nurse
identify as the reason for the client’s memory lapse?
1. Epidural anesthesia
2. The taking-in phase
3. The taking-hold phase
4. Postpartum
hemorrhage Answer: 2
Explanation:
1. Epidural anesthesia is a pharmacologic approach to pain control.
2. The taking-in phase, which occurs during the first day or two following birth, is
characterized by a passive and dependent affect. The mother also might be in need of
food and rest.
3. The taking-hold phase occurs by the second or third day, when the mother is ready
to resume control of life and is open to teaching.
4. Postpartum hemorrhage is a serious complication and will need medical intervention.
5) The nurse is observing a graduate nurse’s assessment of a postpartum client. For
which action by the graduate nurse should the nurse intervene?
1. Asking the client to void before applying clean gloves
2. Instructing visitors to leave the room prior to beginning the assessment
3. Requesting the client lie flat in bed with the head on a pillow prior to the fundal assessment
4. Discussing the effectiveness of comfort measures while performing the perineal
assessment Answer: 2
Explanation:
1. Voiding prior to the assessment helps ensure comfort; clean gloves prevent exposure
to body fluids.
2. The nurse should allow the client to choose whether visitors leave or remain in the
room during the assessment.
3. The supine position prevents a falsely high assessment of fundal height.
4. The assessment provides an excellent opportunity for teaching about good
healthcare practices in both the short and long term, including comfort measures.
6) In which order should the nurse conduct the examination of a postpartum client?
1. L–lochia
2. B–bowel
NURS CM EXAM 3 QUESTIONS WITH ANSWERS CHAPTER 28 to 35 –
POSTPARTUM ADAPTATION AND NURSING ASSESSMENT LATEST
UPDATE 2022
, NURS CM EXAM 3 QUESTIONS WITH ANSWERS CHAPTER 28 to 35 –
POSTPARTUM ADAPTATION AND NURSING ASSESSMENT LATEST
UPDATE 2022
3. B–breast
4. U–uterus
5. B–bladder
6. E–emotional
7. H–Homans/hemorrhoids
8. E–episiotomy/laceration/edema
Answer: 3, 4, 5, 2, 1, 8, 7, 6
Explanation:
1. An easy way to remember the components specific to the postpartum examination is to
remember the term BUBBLEHE: B–breast, U–uterus, B–bladder, B–bowel, L–lochia,
E–episiotomy/laceration/edema, H–Homans/hemorrhoids, E–emotional.
2. An easy way to remember the components specific to the postpartum examination is to
remember the term BUBBLEHE: B–breast, U–uterus, B–bladder, B–bowel, L–lochia,
E–episiotomy/laceration/edema, H–Homans/hemorrhoids, E–emotional.
3. An easy way to remember the components specific to the postpartum examination is to
remember the term BUBBLEHE: B–breast, U–uterus, B–bladder, B–bowel, L–lochia,
E–episiotomy/laceration/edema, H–Homans/hemorrhoids, E–emotional.
4. An easy way to remember the components specific to the postpartum examination is to
remember the term BUBBLEHE: B–breast, U–uterus, B–bladder, B–bowel, L–lochia,
E–episiotomy/laceration/edema, H–Homans/hemorrhoids, E–emotional.
5. An easy way to remember the components specific to the postpartum examination is to
remember the term BUBBLEHE: B–breast, U–uterus, B–bladder, B–bowel, L–lochia,
E–episiotomy/laceration/edema, H–Homans/hemorrhoids, E–emotional.
6. An easy way to remember the components specific to the postpartum examination is to
remember the term BUBBLEHE: B–breast, U–uterus, B–bladder, B–bowel, L–lochia,
E–episiotomy/laceration/edema, H–Homans/hemorrhoids, E–emotional.
7. An easy way to remember the components specific to the postpartum examination is to
remember the term BUBBLEHE: B–breast, U–uterus, B–bladder, B–bowel, L–lochia,
E–episiotomy/laceration/edema, H–Homans/hemorrhoids, E–emotional.
8. An easy way to remember the components specific to the postpartum examination is to
remember the term BUBBLEHE: B–breast, U–uterus, B–bladder, B–bowel, L–lochia,
E–episiotomy/laceration/edema, H–Homans/hemorrhoids, E–emotional.
7) A postpartum client becomes concerned when a gush of blood occurs during the fundal
assessment. What should the nurse explain about this occurrence?
1. “Do not worry. I will make sure everything is fine.”
2. “We see this from time to time. It’s not a big deal.”
3. “Blood has pooled in the vagina while you were in bed.”
4. “The gush is an indication that your fundus is not
contracting.” Answer: 3
Explanation:
1. This response is not therapeutic because it focuses on the nurse and has a “do not
NURS CM EXAM 3 QUESTIONS WITH ANSWERS CHAPTER 28 to 35 –
POSTPARTUM ADAPTATION AND NURSING ASSESSMENT LATEST
UPDATE 2022
, NURS CM EXAM 3 QUESTIONS WITH ANSWERS CHAPTER 28 to 35 –
POSTPARTUM ADAPTATION AND NURSING ASSESSMENT LATEST
UPDATE 2022
worry” aspect that is demeaning.
2. Although a gush of blood during fundus assessment is fairly common, this response is
not therapeutic because it does not address the client’s concern.
3. Because of the angle of the vagina, lochia pools in the vagina while a woman is lying
or semisitting in bed, which leads to a gush when fundal massage is performed.
4. The fundus might be contracting well. The gush is from pooled lochia in the vagina.
8) A postpartum client is not going to breastfeed her newborn. What should the nurse include
when teaching this client about breast care?
1. The let-down reflex
2. Lactation suppression
3. The purpose of fundal massage
4. The cause of afterpains
Answer: 2
Explanation:
1. The let-down reflex is an important teaching point for breastfeeding patients.
2. It is important to teach nonbreastfeeding patients about lactation suppression after delivery.
3. The purpose of fundal massage should be addressed when assessing the uterus and
fundus, not when assessing the breasts.
4. Afterpains can be stimulated by breastfeeding. The nurse will not likely teach
a nonbreastfeeding primipara about afterpains.
9) Every time the nurse enters the client’s room, the client, who delivered 3 hours ago, asks
the nurse something else about the birth experience. What action should the nurse take?
1. Answer questions quickly and try to divert attention to other subjects.
2. Review documentation of the birth experience and discuss it with the client.
3. Contact the healthcare provider because of changes in the client’s memory.
4. Submit a referral to Social Services because of concerns about obsessive
behavior. Answer: 2
Explanation:
1. Answering questions quickly and trying to divert attention to other subjects trivializes the
questions and does not allow the client to sort out the reality from the subjective
experience.
2. Reviewing the documentation of the birth experience and discussing it with the client
helps the client integrate the experience and talk about perceptions of the labor and
delivery experience.
3. The client is not demonstrating changes in memory. The healthcare provider does not
need to be contacted.
4. Submitting a referral to Social Services because of obsessive behavior is not
appropriate. The client is demonstrating normal behavior.
NURS CM EXAM 3 QUESTIONS WITH ANSWERS CHAPTER 28 to 35 –
POSTPARTUM ADAPTATION AND NURSING ASSESSMENT LATEST
UPDATE 2022
