NURSING CARE OF THE FAMILY DURING THE
POSTPARTUM PERIOD CHAPTER- 19 EXAM
2024/2025
Which measure would be least effective in preventing postpartum hemorrhage? -
CORRECT ANSWER Massage the fundus every hour for the first 24 hours following
birth
Administration of Methergine can help prevent postpartum hemorrhage. Voiding
frequently can help the uterus contract, thus preventing postpartum hemorrhage. The
fundus should be massaged only when boggy or soft. Massaging a firm fundus could
cause it to relax. Rest and nutrition are helpful for enhancing healing and preventing
hemorrhage.
Which findings would be a source of concern if noted during the assessment of a
woman who is 12 hours' postpartum? - CORRECT ANSWER Pain in left calf with
dorsiflexion of left foot
Lochia rubra with foul odor
Postural hypotension is an expected finding related to circulatory changes after birth A
temperature of 100.4° F in the first 24 hours most likely indicates dehydration, which is
easily corrected by increasing oral fluid intake. A heart rate of 55 beats/min is an
expected finding in the initial postpartum period. These findings indicate a positive
Homans' sign and are suggestive of thrombophlebitis and should be investigated.
Lochia with odor may indicate infection.
A postpartum woman preparing for discharge asks the nurse about resuming sexual
activity. Which information is appropriate to include in the patient teaching? - CORRECT
ANSWER Fatigue may affect interest in sexual activity.
Sexual activity can usually be safely resumed by 5 to 6 weeks after birth.
Water-soluble lubrication may increase comfort.
The female-on-top position may be more comfortable than other positions.
Kegel exercises are usually recommended and can strengthen the pubococcygeal
muscle. Breastfeeding mothers often are interested in returning to sexual activity before
no breastfeeding mothers. The amount of psychologic energy expended by the mother
in child care activities may lead to fatigue and decreased interest in sexual activity. Most
women can safely resume sexual activity by 5 to 6 weeks after birth. A water-soluble gel
or jelly is recommended for lubrication. A position in which the mother has control of the
depth of insertion of the penis, such as the female-on-top position may be more
comfortable than other positions.
, Two hours after giving birth a primiparous woman becomes anxious and complains of
intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm
at the umbilicus and midline. Her lochia is moderate rubra with no clots. The nurse
suspects: - CORRECT ANSWER hematoma formation
Bladder distention results in an elevation of the fundus above the umbilicus and
deviation to the right or left of midline. Uterine atony results in a boggy fundus.
Constipation is unlikely at this time. Increasing perineal pressure along with a firm
fundus and moderate lochial flow are characteristic of hematoma formation.
On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has
completely saturated a perineal pad within 15 minutes. The nurse's first action is to: -
CORRECT ANSWER massage the woman's fundus.
The nurse may begin an IV infusion to restore circulatory volume, but this would not be
the first action. Blood pressure is not a reliable indicator of impending shock from an
impending hemorrhage; assessing vital signs should not be the nurse's first action. The
physician should be notified after the nurse completes assessment of the woman. The
nurse should assess the uterus for atony. Uterine tone must be established to prevent
excessive blood loss.
Perineal care is an important infection control measure. When evaluating a postpartum
woman's perineal care technique, the nurse would recognize the need for further
instruction if the woman: - CORRECT ANSWER uses the peribottle to rinse upward into
her vagina.
These are all appropriate measures. These are all appropriate measures. These are all
appropriate measures. The peribottle should be used in a backward direction over the
perineum. The flow should never be directed upward into the vagina since debris would
be forced upward into the uterus through the still-open cervix.
When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is
firm, 2 fingerbreadths above the umbilicus, and deviated to the left of midline. The nurse
should: - CORRECT ANSWER assist the woman to empty her bladder.
A firm fundus should not be massaged since massage could overstimulate the fundus
and cause it to relax. Methergine is not indicated in this case since it is an oxytocic and
the fundus is already firm. The findings indicate a full bladder, which pushes the uterus
up and to the right or left of midline. The recommended action would be to empty the
bladder. If the bladder remains distended, uterine atony could occur, resulting in a
profuse flow. This is not a normal finding, and an action is required.
The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline,
and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The
nurse's initial action would be to: - CORRECT ANSWER massage her fundus.
POSTPARTUM PERIOD CHAPTER- 19 EXAM
2024/2025
Which measure would be least effective in preventing postpartum hemorrhage? -
CORRECT ANSWER Massage the fundus every hour for the first 24 hours following
birth
Administration of Methergine can help prevent postpartum hemorrhage. Voiding
frequently can help the uterus contract, thus preventing postpartum hemorrhage. The
fundus should be massaged only when boggy or soft. Massaging a firm fundus could
cause it to relax. Rest and nutrition are helpful for enhancing healing and preventing
hemorrhage.
Which findings would be a source of concern if noted during the assessment of a
woman who is 12 hours' postpartum? - CORRECT ANSWER Pain in left calf with
dorsiflexion of left foot
Lochia rubra with foul odor
Postural hypotension is an expected finding related to circulatory changes after birth A
temperature of 100.4° F in the first 24 hours most likely indicates dehydration, which is
easily corrected by increasing oral fluid intake. A heart rate of 55 beats/min is an
expected finding in the initial postpartum period. These findings indicate a positive
Homans' sign and are suggestive of thrombophlebitis and should be investigated.
Lochia with odor may indicate infection.
A postpartum woman preparing for discharge asks the nurse about resuming sexual
activity. Which information is appropriate to include in the patient teaching? - CORRECT
ANSWER Fatigue may affect interest in sexual activity.
Sexual activity can usually be safely resumed by 5 to 6 weeks after birth.
Water-soluble lubrication may increase comfort.
The female-on-top position may be more comfortable than other positions.
Kegel exercises are usually recommended and can strengthen the pubococcygeal
muscle. Breastfeeding mothers often are interested in returning to sexual activity before
no breastfeeding mothers. The amount of psychologic energy expended by the mother
in child care activities may lead to fatigue and decreased interest in sexual activity. Most
women can safely resume sexual activity by 5 to 6 weeks after birth. A water-soluble gel
or jelly is recommended for lubrication. A position in which the mother has control of the
depth of insertion of the penis, such as the female-on-top position may be more
comfortable than other positions.
, Two hours after giving birth a primiparous woman becomes anxious and complains of
intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm
at the umbilicus and midline. Her lochia is moderate rubra with no clots. The nurse
suspects: - CORRECT ANSWER hematoma formation
Bladder distention results in an elevation of the fundus above the umbilicus and
deviation to the right or left of midline. Uterine atony results in a boggy fundus.
Constipation is unlikely at this time. Increasing perineal pressure along with a firm
fundus and moderate lochial flow are characteristic of hematoma formation.
On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has
completely saturated a perineal pad within 15 minutes. The nurse's first action is to: -
CORRECT ANSWER massage the woman's fundus.
The nurse may begin an IV infusion to restore circulatory volume, but this would not be
the first action. Blood pressure is not a reliable indicator of impending shock from an
impending hemorrhage; assessing vital signs should not be the nurse's first action. The
physician should be notified after the nurse completes assessment of the woman. The
nurse should assess the uterus for atony. Uterine tone must be established to prevent
excessive blood loss.
Perineal care is an important infection control measure. When evaluating a postpartum
woman's perineal care technique, the nurse would recognize the need for further
instruction if the woman: - CORRECT ANSWER uses the peribottle to rinse upward into
her vagina.
These are all appropriate measures. These are all appropriate measures. These are all
appropriate measures. The peribottle should be used in a backward direction over the
perineum. The flow should never be directed upward into the vagina since debris would
be forced upward into the uterus through the still-open cervix.
When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is
firm, 2 fingerbreadths above the umbilicus, and deviated to the left of midline. The nurse
should: - CORRECT ANSWER assist the woman to empty her bladder.
A firm fundus should not be massaged since massage could overstimulate the fundus
and cause it to relax. Methergine is not indicated in this case since it is an oxytocic and
the fundus is already firm. The findings indicate a full bladder, which pushes the uterus
up and to the right or left of midline. The recommended action would be to empty the
bladder. If the bladder remains distended, uterine atony could occur, resulting in a
profuse flow. This is not a normal finding, and an action is required.
The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline,
and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The
nurse's initial action would be to: - CORRECT ANSWER massage her fundus.
