MEDSURGE1010 questions and answers with RATIONALE
graded A+ 2022/2023 UPDATE SUCCESS ASSURED
1.A nurse is caring for a client who is postpartum and received methylergonovine. Which of the
following findings indicates that the medication was effective?
A. Fundus firm to palpation
Rationale: Methylergonovine is an oxytocic medication that is administered to promote uterine
contractions. This medication is indicated for treatment of postpartum hemorrhage
caused by uterine atony or subinvolution; the desired effect is an increase in uterine
tone.
B. Increase in blood pressure
Rationale: A rise in blood pressure is an adverse effect of the medication.
C. Increase in lochia
Rationale: This finding would indicate the medication was not effective.
D. Report of absent breast pain
Rationale: Methylergonovine has no effect on breast discomfort.
2.A nurse is assessing a client who is 4 hr postpartum following a vaginal delivery. Which of the
following findings should the nurse identify as the priority?
A. Saturated perineal pad in 30 min
Rationale: The client will have lochia rubra for the first 1 to 3 days. A saturated perineal pad in
15 min or less can indicate excessive bleeding. Therefore, the nurse should not
identify this as the priority finding. The nurse should also monitor for blood under
the client's buttocks.
B. Deep tendon reflexes 4+
Rationale: Deep tendon reflexes 4+ are hyperactive and indicate that the client is at
greatest risk for preeclampsia and seizures. The nurse should identify this as the
priority finding. The nurse should also monitor for headaches, visual
disturbances and epigastric pain. The provider will likely prescribe magnesium
sulfate IV infusion.
C. Fundus at level of umbilicus
Rationale: The client's fundus should be firm, midline, and at the level of the umbilicus for
the first 24 hr after delivery. The fundus will involute approximately 1 cm/day and
will descend 1 to 2 cm/day. Therefore, the nurse should not identify this as the
priority finding.
D. Approximated edges of episiotomy
Rationale: Approximated edges of the episiotomy indicate good wound healing.
Therefore, the nurse should not identify this as the priority finding. Redness,
warmth, and drainage can indicate infection.
MEDSURGE1010 questions and answers with RATIONALE
graded A+ 2022/2023 UPDATE SUCCESS ASSURED
Page 1
,MEDSURGE1010 questions and answers with RATIONALE
graded A+ 2022/2023 UPDATE SUCCESS ASSURED
3.A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and
several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus.
Which of the following actions should the nurse take?
A. Document the findings and continue to monitor the client.
Rationale: These are expected findings. At 1 hr postpartum, lochia rubra should be
intermittent and associated with uterine contractions. The volume of lochia
resembles that of a heavy menstrual period. Small clots are common. The nurse
should document the findings and continue to monitor the client.
B. Notify the client’s provider.
Rationale: These are expected findings, so there is no need to notify the provider.
C. Increase the frequency of fundal massage.
Rationale: These are expected findings and the fundus is already firm. Increasing the frequency
of fundal massage is not indicated at this time.
D. Encourage the client to empty her bladder.
Rationale: These are expected findings, and the fundus is firm at the midline. If the fundus was
deviated, this would be an indication of a distended bladder and the client should be
encouraged to void to prevent uterine atony.
4.A nurse is teaching a client who is postpartum and has been diagnosed with iron deficiency
anemia. Which of the following dietary recommendations should the nurse include in the teaching
plan?
A. Yogurt and mozzarella
Rationale: Yogurt and mozzarella cheese are sources of calcium and protein and are not high in
iron and therefore would not be recommended for this client as sources of iron.
B. Spinach and beef
Rationale: Spinach and beef are high in iron and would be recommended for this client.
C. Milk and turkey slices
Rationale: Milk is a source of calcium and protein, and turkey is a source of protein. They are
not high in iron and would not be recommended for this client as sources of iron.
D. Fish and cottage cheese
Rationale: Fish is a source of protein, and cottage cheese is a source of protein and calcium.
They are not high in iron and would not be recommended for this client as sources
of iron.
5.A nurse is performing a physical examination of a client who is 1 day postpartum. Which of the
MEDSURGE1010 questions and answers with RATIONALE
graded A+ 2022/2023 UPDATE SUCCESS ASSURED
Page 2
,MEDSURGE1010 questions and answers with RATIONALE
graded A+ 2022/2023 UPDATE SUCCESS ASSURED
following findings requires immediate intervention?
MEDSURGE1010 questions and answers with RATIONALE
graded A+ 2022/2023 UPDATE SUCCESS ASSURED
Page 3
, MEDSURGE1010 questions and answers with RATIONALE
graded A+ 2022/2023 UPDATE SUCCESS ASSURED
A. Decreased urge to void
Rationale: This is an expected finding in the postpartum period and does not require
immediate intervention. Birth trauma, increased bladder capacity after childbirth,
and anesthesia can cause a decreased urge to void. Pelvic soreness caused by the
forces of labor, vaginal lacerations, or an episiotomy reduces or alters the voiding
reflex. The nurse should monitor the client’s voiding pattern.
B. Increased urine output
Rationale: Within 12 hr of birth, clients begin to lose the excess tissue fluid accumulated during
pregnancy.
Postpartum diuresis is caused by decreased estrogen levels. This is an expected
finding and does not require immediate intervention.
C. Displaced fundus from the midline
Rationale: A distended bladder can cause uterine atony and lateral displacement of the fundus
from the midline of the lower abdomen, usually to the right. This requires
immediate intervention because the distended bladder pushes the uterus up and to
the side, which prevents it from contracting firmly. Uterine atony results from the
inability of the uterine muscle to contract adequately after birth. This can lead to
postpartum hemorrhage.
D. Fundal height below the umbilicus
Rationale: Involution is the return of the uterus to a nonpregnant state. At the end of the third
stage of labor, the uterus is in the midline, approximately 2 cm below the level of
the umbilicus. Within 12 hr, the fundus rises to approximately the level of the
umbilicus. The fundus descends 1 to 2 cm every 24 hr. Therefore, at 1 day
postpartum, the fundal height should be 1 to 2 cm (fingerbreadths) below the
umbilicus. This is an expected finding and does not require immediate intervention.
6.A nurse is caring a client who is 3 days postpartum and is attempting to breastfeed. Which of the
following findings indicate mastitis?
A. Swelling in both breasts
Rationale: Because the swelling is present in both breasts and there is no redness or pain, this
client is likely to have engorgement. The nurse should assist the client to
breastfeed frequently and apply ice packs or cold compresses after breastfeeding.
B. Cracked and bleeding nipples
Rationale: Tenderness of the nipples is expected in the first few days of breastfeeding.
Cracking and bleeding nipples, however, is an indication that the infant's position
and/or feeding method is incorrect. The nurse should instruct the mother to clean
the nipples with water and apply a thin layer of a topical antibiotic cream or
ointment after breastfeeding.
C. Red and painful area in one breast
Rationale: Mastitis often appears as a red, hard, and painful area on the breast, commonly in
the upper outer quadrant. Although mastitis can occur in both breasts, it is usually
MEDSURGE1010 questions and answers with RATIONALE
graded A+ 2022/2023 UPDATE SUCCESS ASSURED
Page 4
graded A+ 2022/2023 UPDATE SUCCESS ASSURED
1.A nurse is caring for a client who is postpartum and received methylergonovine. Which of the
following findings indicates that the medication was effective?
A. Fundus firm to palpation
Rationale: Methylergonovine is an oxytocic medication that is administered to promote uterine
contractions. This medication is indicated for treatment of postpartum hemorrhage
caused by uterine atony or subinvolution; the desired effect is an increase in uterine
tone.
B. Increase in blood pressure
Rationale: A rise in blood pressure is an adverse effect of the medication.
C. Increase in lochia
Rationale: This finding would indicate the medication was not effective.
D. Report of absent breast pain
Rationale: Methylergonovine has no effect on breast discomfort.
2.A nurse is assessing a client who is 4 hr postpartum following a vaginal delivery. Which of the
following findings should the nurse identify as the priority?
A. Saturated perineal pad in 30 min
Rationale: The client will have lochia rubra for the first 1 to 3 days. A saturated perineal pad in
15 min or less can indicate excessive bleeding. Therefore, the nurse should not
identify this as the priority finding. The nurse should also monitor for blood under
the client's buttocks.
B. Deep tendon reflexes 4+
Rationale: Deep tendon reflexes 4+ are hyperactive and indicate that the client is at
greatest risk for preeclampsia and seizures. The nurse should identify this as the
priority finding. The nurse should also monitor for headaches, visual
disturbances and epigastric pain. The provider will likely prescribe magnesium
sulfate IV infusion.
C. Fundus at level of umbilicus
Rationale: The client's fundus should be firm, midline, and at the level of the umbilicus for
the first 24 hr after delivery. The fundus will involute approximately 1 cm/day and
will descend 1 to 2 cm/day. Therefore, the nurse should not identify this as the
priority finding.
D. Approximated edges of episiotomy
Rationale: Approximated edges of the episiotomy indicate good wound healing.
Therefore, the nurse should not identify this as the priority finding. Redness,
warmth, and drainage can indicate infection.
MEDSURGE1010 questions and answers with RATIONALE
graded A+ 2022/2023 UPDATE SUCCESS ASSURED
Page 1
,MEDSURGE1010 questions and answers with RATIONALE
graded A+ 2022/2023 UPDATE SUCCESS ASSURED
3.A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and
several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus.
Which of the following actions should the nurse take?
A. Document the findings and continue to monitor the client.
Rationale: These are expected findings. At 1 hr postpartum, lochia rubra should be
intermittent and associated with uterine contractions. The volume of lochia
resembles that of a heavy menstrual period. Small clots are common. The nurse
should document the findings and continue to monitor the client.
B. Notify the client’s provider.
Rationale: These are expected findings, so there is no need to notify the provider.
C. Increase the frequency of fundal massage.
Rationale: These are expected findings and the fundus is already firm. Increasing the frequency
of fundal massage is not indicated at this time.
D. Encourage the client to empty her bladder.
Rationale: These are expected findings, and the fundus is firm at the midline. If the fundus was
deviated, this would be an indication of a distended bladder and the client should be
encouraged to void to prevent uterine atony.
4.A nurse is teaching a client who is postpartum and has been diagnosed with iron deficiency
anemia. Which of the following dietary recommendations should the nurse include in the teaching
plan?
A. Yogurt and mozzarella
Rationale: Yogurt and mozzarella cheese are sources of calcium and protein and are not high in
iron and therefore would not be recommended for this client as sources of iron.
B. Spinach and beef
Rationale: Spinach and beef are high in iron and would be recommended for this client.
C. Milk and turkey slices
Rationale: Milk is a source of calcium and protein, and turkey is a source of protein. They are
not high in iron and would not be recommended for this client as sources of iron.
D. Fish and cottage cheese
Rationale: Fish is a source of protein, and cottage cheese is a source of protein and calcium.
They are not high in iron and would not be recommended for this client as sources
of iron.
5.A nurse is performing a physical examination of a client who is 1 day postpartum. Which of the
MEDSURGE1010 questions and answers with RATIONALE
graded A+ 2022/2023 UPDATE SUCCESS ASSURED
Page 2
,MEDSURGE1010 questions and answers with RATIONALE
graded A+ 2022/2023 UPDATE SUCCESS ASSURED
following findings requires immediate intervention?
MEDSURGE1010 questions and answers with RATIONALE
graded A+ 2022/2023 UPDATE SUCCESS ASSURED
Page 3
, MEDSURGE1010 questions and answers with RATIONALE
graded A+ 2022/2023 UPDATE SUCCESS ASSURED
A. Decreased urge to void
Rationale: This is an expected finding in the postpartum period and does not require
immediate intervention. Birth trauma, increased bladder capacity after childbirth,
and anesthesia can cause a decreased urge to void. Pelvic soreness caused by the
forces of labor, vaginal lacerations, or an episiotomy reduces or alters the voiding
reflex. The nurse should monitor the client’s voiding pattern.
B. Increased urine output
Rationale: Within 12 hr of birth, clients begin to lose the excess tissue fluid accumulated during
pregnancy.
Postpartum diuresis is caused by decreased estrogen levels. This is an expected
finding and does not require immediate intervention.
C. Displaced fundus from the midline
Rationale: A distended bladder can cause uterine atony and lateral displacement of the fundus
from the midline of the lower abdomen, usually to the right. This requires
immediate intervention because the distended bladder pushes the uterus up and to
the side, which prevents it from contracting firmly. Uterine atony results from the
inability of the uterine muscle to contract adequately after birth. This can lead to
postpartum hemorrhage.
D. Fundal height below the umbilicus
Rationale: Involution is the return of the uterus to a nonpregnant state. At the end of the third
stage of labor, the uterus is in the midline, approximately 2 cm below the level of
the umbilicus. Within 12 hr, the fundus rises to approximately the level of the
umbilicus. The fundus descends 1 to 2 cm every 24 hr. Therefore, at 1 day
postpartum, the fundal height should be 1 to 2 cm (fingerbreadths) below the
umbilicus. This is an expected finding and does not require immediate intervention.
6.A nurse is caring a client who is 3 days postpartum and is attempting to breastfeed. Which of the
following findings indicate mastitis?
A. Swelling in both breasts
Rationale: Because the swelling is present in both breasts and there is no redness or pain, this
client is likely to have engorgement. The nurse should assist the client to
breastfeed frequently and apply ice packs or cold compresses after breastfeeding.
B. Cracked and bleeding nipples
Rationale: Tenderness of the nipples is expected in the first few days of breastfeeding.
Cracking and bleeding nipples, however, is an indication that the infant's position
and/or feeding method is incorrect. The nurse should instruct the mother to clean
the nipples with water and apply a thin layer of a topical antibiotic cream or
ointment after breastfeeding.
C. Red and painful area in one breast
Rationale: Mastitis often appears as a red, hard, and painful area on the breast, commonly in
the upper outer quadrant. Although mastitis can occur in both breasts, it is usually
MEDSURGE1010 questions and answers with RATIONALE
graded A+ 2022/2023 UPDATE SUCCESS ASSURED
Page 4
