Maternity Nursing 2 of 2 questions and
answers 2025/2026
The client received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours.
At 6 hours postpartum, the client's systolic blood pressure (BP) dropped20 points, the diastolic BP
dropped 10 points, and her pulse is120 beats per minute. The client is very anxious and restless. The
nurse is told that the client has a vulvar hematoma. On the basis of this diagnosis, the nurse would plan
to:
1. Reassure the client.
2. Apply perineal pressure.
3. Monitor the fundal height.
4. Prepare the client for surgery. - Answer 4. Prepare the client for surgery.
Rationale: The information provided in the question indicates that the client
is experiencing blood loss. Surgery would be indicated for this complication
to stop the bleeding. Options 1, 2, and 3 would not assist with controlling the
bleeding in this emergency situation.
Test-Taking Strategy: Focus on the information provided in the question and
note that the client has a vulvar hematoma. Note that the signs and
symptoms in the question indicate the presence of bleeding; this should
direct you to the correct option. Review the nursing interventions related to
vulvar hematomas if you had difficulty with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Maternity/Postpartum
References: Leifer, p. 239. 2011.
McKinney, James, Murray, Ashwill, p. 698. 2009.
The nurse is assigned to care for the client after a cesarean section. To prevent thrombophlebitis, the
nurse encourages the woman to take which priority action?
,1. Ambulate frequently.
2. Wear support stockings.
3. Apply warm, moist packs to the legs.
4. Remain on bed rest, with the legs elevated. - Answer 1. Ambulate frequently.
Rationale: Stasis is believed to be a major predisposing factor for the
development of thrombophlebitis. Because cesarean delivery poses a risk
factor, the client should ambulate early and frequently to promote
circulation and prevent stasis. Options 2, 3, and 4 are implemented if
thrombophlebitis occurs.
Test-Taking Strategy: Focus on the subject of the question, the prevention of
thrombophlebitis, and note the strategic word "priority." Options 3 and 4 are
implemented if thrombophlebitis occurs. Although wearing support stockings
may be prescribed in the postoperative period to promote venous return,
ambulating frequently (option 1) is the priority preventive measure. Review
the content related to the prevention of thrombophlebitis during the
postoperative period if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Postpartum
Reference: Leifer, p. 210. 2011.
A postpartum client is getting ready for discharge. The nurse suspects that the client is in need of further
teaching related to breast-feeding when she states:
1. "I don't need birth control since I will be breast-feeding."
2. "I need to increase my caloric intake by 500 calories a day."
3. "I shouldn't use soap to wash my breasts since I will bebreast-feeding."
,4. "I need to be sure that I increase my fluid intake and take my prenatal vitamins while breast-feeding."
- Answer 1. "I don't need birth control since I will be breast-feeding."
Rationale: Amenorrhea may occur during breast-feeding, but the client can
still ovulate without menstruating. The use of soap on the breasts is avoided
because it tends to remove natural oils, which can lead to cracked nipples.
The caloric intake should be increased by 200 to 500 cal/day (per health
care provider's prescription), and the diet should include additional fluids
and prenatal vitamins, as prescribed.
Test-Taking Strategy: Note the strategic words "need of further teaching."
These words indicate a negative event query and the need to select the
incorrect statement. Recalling the physiology related to amenorrhea and
ovulation during breast-feeding will direct you to the correct option. Review
teaching points for the woman who is breast-feeding if you had difficulty
answering this question.
Level of Cognitive Ability: Evaluating
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching and Learning
Content Area: Maternity/Postpartum
Reference: Leifer, p. 266. 2011.
The nurse is caring for a postpartum client with a diagnosis of thrombophlebitis. The client suddenly
complains of chest pain and dyspnea. The nurse would initially check the:
1. Vital signs
2. Fundal height
3. Presence of calf pain
4. Level of consciousness (LOC) - Answer 1. Vital signs
Rationale: Pulmonary embolism is a complication of thrombophlebitis.
Changes in the vital signs are one of the first things to occur with pulmonary
, embolism, because pulmonary blood flow is compromised. Fundal height is
unrelated to the subject of the question. Calf pain is an indicator of
thrombophlebitis. Level of consciousness may change as the condition
worsens; worsening would indicate hypoxia.
Test-Taking Strategy: Note the strategic word "initially." Use the ABCs—
airway, breathing, and circulation—to direct you to the correct option.
Review the complications of thrombophlebitis if you had difficulty with this
question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Critical Care
References: Christensen, Kockrow, pp. 913-914. 2011. Foundations of nursing.
Leifer, pp. 240-241. 2011.
The nurse suspects that the client has a pulmonary embolism. The most important nursing action is to:
1. Monitor the vital signs.
2. Elevate the head of the bed.
3. Increase the intravenous flow rate.
4. Administer oxygen by face mask, as prescribed. - Answer 4. Administer oxygen by face mask, as
prescribed.
Rationale: Because pulmonary circulation is compromised in the presence of
an embolus, cardiorespiratory support is initiated by oxygen administration.
Options 1 and 2 may be components of the plan of care, but they are not the
most important actions. The nurse would not increase the intravenous rate
without a prescription from the health care provider to do so.
Test-Taking Strategy: Note the strategic words "most important," and use
answers 2025/2026
The client received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours.
At 6 hours postpartum, the client's systolic blood pressure (BP) dropped20 points, the diastolic BP
dropped 10 points, and her pulse is120 beats per minute. The client is very anxious and restless. The
nurse is told that the client has a vulvar hematoma. On the basis of this diagnosis, the nurse would plan
to:
1. Reassure the client.
2. Apply perineal pressure.
3. Monitor the fundal height.
4. Prepare the client for surgery. - Answer 4. Prepare the client for surgery.
Rationale: The information provided in the question indicates that the client
is experiencing blood loss. Surgery would be indicated for this complication
to stop the bleeding. Options 1, 2, and 3 would not assist with controlling the
bleeding in this emergency situation.
Test-Taking Strategy: Focus on the information provided in the question and
note that the client has a vulvar hematoma. Note that the signs and
symptoms in the question indicate the presence of bleeding; this should
direct you to the correct option. Review the nursing interventions related to
vulvar hematomas if you had difficulty with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Maternity/Postpartum
References: Leifer, p. 239. 2011.
McKinney, James, Murray, Ashwill, p. 698. 2009.
The nurse is assigned to care for the client after a cesarean section. To prevent thrombophlebitis, the
nurse encourages the woman to take which priority action?
,1. Ambulate frequently.
2. Wear support stockings.
3. Apply warm, moist packs to the legs.
4. Remain on bed rest, with the legs elevated. - Answer 1. Ambulate frequently.
Rationale: Stasis is believed to be a major predisposing factor for the
development of thrombophlebitis. Because cesarean delivery poses a risk
factor, the client should ambulate early and frequently to promote
circulation and prevent stasis. Options 2, 3, and 4 are implemented if
thrombophlebitis occurs.
Test-Taking Strategy: Focus on the subject of the question, the prevention of
thrombophlebitis, and note the strategic word "priority." Options 3 and 4 are
implemented if thrombophlebitis occurs. Although wearing support stockings
may be prescribed in the postoperative period to promote venous return,
ambulating frequently (option 1) is the priority preventive measure. Review
the content related to the prevention of thrombophlebitis during the
postoperative period if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Postpartum
Reference: Leifer, p. 210. 2011.
A postpartum client is getting ready for discharge. The nurse suspects that the client is in need of further
teaching related to breast-feeding when she states:
1. "I don't need birth control since I will be breast-feeding."
2. "I need to increase my caloric intake by 500 calories a day."
3. "I shouldn't use soap to wash my breasts since I will bebreast-feeding."
,4. "I need to be sure that I increase my fluid intake and take my prenatal vitamins while breast-feeding."
- Answer 1. "I don't need birth control since I will be breast-feeding."
Rationale: Amenorrhea may occur during breast-feeding, but the client can
still ovulate without menstruating. The use of soap on the breasts is avoided
because it tends to remove natural oils, which can lead to cracked nipples.
The caloric intake should be increased by 200 to 500 cal/day (per health
care provider's prescription), and the diet should include additional fluids
and prenatal vitamins, as prescribed.
Test-Taking Strategy: Note the strategic words "need of further teaching."
These words indicate a negative event query and the need to select the
incorrect statement. Recalling the physiology related to amenorrhea and
ovulation during breast-feeding will direct you to the correct option. Review
teaching points for the woman who is breast-feeding if you had difficulty
answering this question.
Level of Cognitive Ability: Evaluating
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching and Learning
Content Area: Maternity/Postpartum
Reference: Leifer, p. 266. 2011.
The nurse is caring for a postpartum client with a diagnosis of thrombophlebitis. The client suddenly
complains of chest pain and dyspnea. The nurse would initially check the:
1. Vital signs
2. Fundal height
3. Presence of calf pain
4. Level of consciousness (LOC) - Answer 1. Vital signs
Rationale: Pulmonary embolism is a complication of thrombophlebitis.
Changes in the vital signs are one of the first things to occur with pulmonary
, embolism, because pulmonary blood flow is compromised. Fundal height is
unrelated to the subject of the question. Calf pain is an indicator of
thrombophlebitis. Level of consciousness may change as the condition
worsens; worsening would indicate hypoxia.
Test-Taking Strategy: Note the strategic word "initially." Use the ABCs—
airway, breathing, and circulation—to direct you to the correct option.
Review the complications of thrombophlebitis if you had difficulty with this
question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Critical Care
References: Christensen, Kockrow, pp. 913-914. 2011. Foundations of nursing.
Leifer, pp. 240-241. 2011.
The nurse suspects that the client has a pulmonary embolism. The most important nursing action is to:
1. Monitor the vital signs.
2. Elevate the head of the bed.
3. Increase the intravenous flow rate.
4. Administer oxygen by face mask, as prescribed. - Answer 4. Administer oxygen by face mask, as
prescribed.
Rationale: Because pulmonary circulation is compromised in the presence of
an embolus, cardiorespiratory support is initiated by oxygen administration.
Options 1 and 2 may be components of the plan of care, but they are not the
most important actions. The nurse would not increase the intravenous rate
without a prescription from the health care provider to do so.
Test-Taking Strategy: Note the strategic words "most important," and use
