Practice Test Questions & Answers
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Graded A+
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?
Instruct the mother to request help when getting out of bed
Rationale: 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. Obtaining an H/H requires a physician's order.
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?
Ask the mother to urinate and empty her bladder
Rationale: Before starting the fundal assessment, the nurse should ask the mother to empty
her bladder so that an accurate assessment can be done. When the nurse is performing a
fundal assessment, the nurse asks the woman to lie flat on her back with her knees flexed.
Massaging the fundus is not appropriate unless the fundus is boggy and soft, and then it
should be massaged gently until firm.
.
The nurse is assessing the lochia on a 1 day PP patient. The nurse notes that the lochia is
red and has a foul-smelling odor. The nurse determines that this assessment finding is:
Indicates the presence of infection
,Updated Postpartum NCLEX
Practice Test Questions & Answers
(latest 2024)|Accurate |100%
Graded A+
Rationale: Lochia, the discharge present after birth, is red for the first 1 to 3 days and
gradually decreases in amount. Normal lochia has a fleshy odor. Foul-smelling or purulent
lochia usually indicates infection, and these findings are not normal. Encouraging the woman
to drink fluids or increase ambulation is not an accurate nursing intervention
.
When performing a PP assessment on a client, the nurse notes the presence of clots in the
lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which of the
following nursing actions is most appropriate?
Notify the physician
Rationale: Normally, one may find a few small clots in the first 1 to 2 days after birth from
pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of
these clots, such as uterine atony or retained placental fragments, needs to be determined
and treated to prevent further blood loss. Although the findings would be documented, the
most appropriate action is to notify the physician.
.
A nurse in a PP unit is instructing a mother regarding lochia and the amount of expected
lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary
but should never exceed the need for:
Eight peripads per day
Rationale: The normal amount of lochia may vary with the individual but should never
exceed 4 to 8 peripads per day. The average number of peripads is 6 per day.
.
A PP nurse is providing instructions to a woman after delivery of a healthy newborn infant.
The nurse instructs the mother that she should expect normal bowel elimination to return:
, Updated Postpartum NCLEX
Practice Test Questions & Answers
(latest 2024)|Accurate |100%
Graded A+
3 days PP
Rationale: After birth, the nurse should auscultate the woman's abdomen in all four
quadrants to determine the return of bowel sounds. Normal bowel elimination usually
returns 2 to 3 days PP. Surgery, anesthesia, and the use of narcotics and pain control agents
also contribute to the longer period of altered bowel function
.
Select all of the physiological maternal changes that occur during the PP period. (Select all
that apply)
Cervical involution occurs
Fundus begins to descend into the pelvis after 24 hours
Rationale: After 1 week the muscle begins to regenerate and the cervix feels firm and the
external os is the width of a pencil. Although the vaginal mucosa heals and vaginal
distention decreases, it takes the entire PP period for complete involution to occur and
muscle tone is never restored to the pregravid state. The fundus begins to descent into the
pelvic cavity after 24 hours, a process known as involution. Despite blood loss that occurs
during the delivery of the baby, a transient increase in cardiac output occurs. The increase
in cardiac output, which persists about 48 hours after childbirth, is probably caused by an
increase in stroke volume because Bradycardia is often noted during the PP period. Soon
after childbirth, digestion begins to begin to be active and the new mother is usually hungry
because of the energy expended during labor.
.
A nurse is caring for a PP woman who has received epidural anesthesia and is monitoring the
woman for the presence of a vulva hematoma. Which of the following assessment findings
would best indicate the presence of a hematoma?
Changes in vital signs
Rationale: Because the woman has had epidural anesthesia and is anesthetized, she cannot
feel pain, pressure, or a tearing sensation. Changes in vitals indicate hypovolemia in the