1
NUR 131 STUDY GUIDE NEWEST VERSION -2025/2026- 100+ Q
AND ANS MOST POPULAR EXAM GUARANTEED SUCCESS
The postpartum nurse who is reviewing the client assignment determines that
which client is at greatest risk for primary (early) postpartum hemorrhage?
A. A client with an infant weighing 5 pounds 7 ounces
B. A client who is 17 years old
C. A client with endometriosis
D. A client with uterine atony
D. A client with uterine atony
Uterine atony accounts for majority of early (within first 24 hours) hemorrhage -
fundal massage
What is the normal PP assessment?
- Breasts: inspect nipples, breast tissue, color
- Fundus: firm, midline - if soft; massage fundus in circular motion / if displaced
have client empty bladder
- Bladder: time of last void / color, odor, amount
- Bowels: last BM
- Lochia: color, amount, presence of clots
- - - Ask when last changed pad
, 2
- - - Rubra - serosa - alba
- - - Scant, small, moderate, heavy
- Incision / episiotomy: type, tissue, trauma, redness
- - - Ice to perineum
- Legs (Homans Sign): pain varicosities, pedal pulses
- Emotions: affect, pt/family interaction
- Bonding: "taking-in" phase - gazing, enfolding, calling by name
- - - Allow client to talk about experience
Normal Lab Values:
- WBC: 12-13,000 (elevated during 3rd trimester and stays elevated postpartum
- HCT: 34-46
- HGB: 12-16
- Vital Signs: 100.-70 (first 6-10 days)
Teaching:
- Supportive bra to help with breast engorgement
- Warm water to help with let down
- Check fundus several times a day
- Notify MD of foul smelling lochia / heavy bleeding
- 2-3 days before normal BM
What are other risk factors for early PP hemorrhage?
, 3
- Cervical lacerations - firm fundus, continuous trickle of bright red blood - notify
health care provider
- Larger for gestation babies - uterine atony - over distended uterus / boggy
- Retained placental tissue - boggy uterus
- Ruptured uterus
Risk factors for late PP hemorrhage? (24 hours - 6 weeks post birth)
- Uterine infection
- Endometritis - foul smelling lochia, uterine tenderness - abx / treat symptoms
- Subinvolution - boggy fundus / higher than normal / heavy discharge
- Retained placental tissue - boggy uterus
Assessment for PPH:
- Restlessness, LOC, vague complaints
- Increase pulse / decrease BP
- Bleeding - describe / amount
- Uterus - firm or boggy
A nurse knows that maintaining a newborn's axillary body temperature between
97.7 (36.5 C) and 99.5 (37.5 C) is an appropriate outcome. To accomplish this
outcome the nurse should:
Select all that apply
, 4
A. Dry the infant immediately after birth
B. Place the infant skin to skin with the mother
C. Apply leggings to the infant's legs
D. Cover the infant's head with a stocking cap
E. Place the infant in a crib close to the delivery room wall
F. Wrap the infant in warm blankets and place him under a radiant heat source
A. Dry the infant immediately after birth
B. Place the infant skin to skin with the mother
D. Cover the infant's head with a stocking cap
- Drying the new born immediate;y after birth prevents heat loss through
evaporation. Skin-to-skin contact assists to maintain newborn body temperature.
Head is dried first and a stocking cap placed to conserve heat.
- Wrap baby in warmed blankets to reduce heat loss via convection (from body
surface to cooler temp)
- Avoid placing by wall to prevent loss through radiation (loss of body heat to
cooler solid surfaces not in direct contact)
Thermoregulation:
- Normal temp: 97.7 - 99.5
- If 97.5 - place skin-to-skin on mother
- - - Warm by 1/2 - 1 degress
- - - Help maintain temperatue
- - - Promotes breastfeeding and bonding
NUR 131 STUDY GUIDE NEWEST VERSION -2025/2026- 100+ Q
AND ANS MOST POPULAR EXAM GUARANTEED SUCCESS
The postpartum nurse who is reviewing the client assignment determines that
which client is at greatest risk for primary (early) postpartum hemorrhage?
A. A client with an infant weighing 5 pounds 7 ounces
B. A client who is 17 years old
C. A client with endometriosis
D. A client with uterine atony
D. A client with uterine atony
Uterine atony accounts for majority of early (within first 24 hours) hemorrhage -
fundal massage
What is the normal PP assessment?
- Breasts: inspect nipples, breast tissue, color
- Fundus: firm, midline - if soft; massage fundus in circular motion / if displaced
have client empty bladder
- Bladder: time of last void / color, odor, amount
- Bowels: last BM
- Lochia: color, amount, presence of clots
- - - Ask when last changed pad
, 2
- - - Rubra - serosa - alba
- - - Scant, small, moderate, heavy
- Incision / episiotomy: type, tissue, trauma, redness
- - - Ice to perineum
- Legs (Homans Sign): pain varicosities, pedal pulses
- Emotions: affect, pt/family interaction
- Bonding: "taking-in" phase - gazing, enfolding, calling by name
- - - Allow client to talk about experience
Normal Lab Values:
- WBC: 12-13,000 (elevated during 3rd trimester and stays elevated postpartum
- HCT: 34-46
- HGB: 12-16
- Vital Signs: 100.-70 (first 6-10 days)
Teaching:
- Supportive bra to help with breast engorgement
- Warm water to help with let down
- Check fundus several times a day
- Notify MD of foul smelling lochia / heavy bleeding
- 2-3 days before normal BM
What are other risk factors for early PP hemorrhage?
, 3
- Cervical lacerations - firm fundus, continuous trickle of bright red blood - notify
health care provider
- Larger for gestation babies - uterine atony - over distended uterus / boggy
- Retained placental tissue - boggy uterus
- Ruptured uterus
Risk factors for late PP hemorrhage? (24 hours - 6 weeks post birth)
- Uterine infection
- Endometritis - foul smelling lochia, uterine tenderness - abx / treat symptoms
- Subinvolution - boggy fundus / higher than normal / heavy discharge
- Retained placental tissue - boggy uterus
Assessment for PPH:
- Restlessness, LOC, vague complaints
- Increase pulse / decrease BP
- Bleeding - describe / amount
- Uterus - firm or boggy
A nurse knows that maintaining a newborn's axillary body temperature between
97.7 (36.5 C) and 99.5 (37.5 C) is an appropriate outcome. To accomplish this
outcome the nurse should:
Select all that apply
, 4
A. Dry the infant immediately after birth
B. Place the infant skin to skin with the mother
C. Apply leggings to the infant's legs
D. Cover the infant's head with a stocking cap
E. Place the infant in a crib close to the delivery room wall
F. Wrap the infant in warm blankets and place him under a radiant heat source
A. Dry the infant immediately after birth
B. Place the infant skin to skin with the mother
D. Cover the infant's head with a stocking cap
- Drying the new born immediate;y after birth prevents heat loss through
evaporation. Skin-to-skin contact assists to maintain newborn body temperature.
Head is dried first and a stocking cap placed to conserve heat.
- Wrap baby in warmed blankets to reduce heat loss via convection (from body
surface to cooler temp)
- Avoid placing by wall to prevent loss through radiation (loss of body heat to
cooler solid surfaces not in direct contact)
Thermoregulation:
- Normal temp: 97.7 - 99.5
- If 97.5 - place skin-to-skin on mother
- - - Warm by 1/2 - 1 degress
- - - Help maintain temperatue
- - - Promotes breastfeeding and bonding
