Postpartum Nursing Care and Maternal
Assessment Essentials
A PP nurse is preparing to care for a woman who has just delivered a healthy newborn infant. In the
immediate PP period the nurse plans to take the woman's vital signs every? - ✔✔Every 15 minutes
during the first hour and then every 30 minutes for the next two hours.
A PP nurse is taking the VS of a woman who delivers a healthy newborn infant 4 hours ago. The nurse
notes that the mother's temperature is 100.2F. Which of the following actions would be most
appropriate? - ✔✔Increase hydration by encouraging oral fluids.
The mother's temperature may be taken every 4 hours while she is awake. Temperatures up to 100.4 F
(38 C) in the first 24 hours after birth are often related to the dehydrating effects of labor. The most
appropriate action is to increase hydration by encouraging oral fluids, which should bring the
temperature to a normal reading.
• Option C: Although the nurse would document the findings, the most appropriate action would be to
increase the hydration.
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?
lightheadedness and dizziness have subsided. - ✔✔Instruct the mother to request help when getting out
of bed.
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.
• Option A: 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.
Before starting the fundal assessment, the nurse should ask the mother to empty her bladder so that an
accurate assessment can be done.
• Options A and B: When the nurse is performing a fundal assessment, the nurse asks the woman to lie
flat on her back with the knees flexed.
• Option D: 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.
Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in
amount. Foul smelling or purulent lochia usually indicates infection, and these findings are not normal.
• Option A: Normal lochia has a fleshy odor.
• Options C and D: 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?
D. Encourage increased intake of fluids. - ✔✔Notify the physician.
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.
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: - ✔✔3 days PP.
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.
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: - ✔✔A and C.
In the PP period, cervical healing occurs rapidly and cervical involution occurs.
After 1 week the muscle begins to regenerate and the cervix feels firm and the external os, is the width
of a pencil. The fundus begins to descent into the pelvic cavity after 24 hours, a process known as
involution.
• Option B: 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.
• Option D: Despite blood loss that occurs during 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.
• Option E: Soon after childbirth, digestion begins to begin to be active, and the new mother is usually
hungry because of the energy expended during labor.
Assessment Essentials
A PP nurse is preparing to care for a woman who has just delivered a healthy newborn infant. In the
immediate PP period the nurse plans to take the woman's vital signs every? - ✔✔Every 15 minutes
during the first hour and then every 30 minutes for the next two hours.
A PP nurse is taking the VS of a woman who delivers a healthy newborn infant 4 hours ago. The nurse
notes that the mother's temperature is 100.2F. Which of the following actions would be most
appropriate? - ✔✔Increase hydration by encouraging oral fluids.
The mother's temperature may be taken every 4 hours while she is awake. Temperatures up to 100.4 F
(38 C) in the first 24 hours after birth are often related to the dehydrating effects of labor. The most
appropriate action is to increase hydration by encouraging oral fluids, which should bring the
temperature to a normal reading.
• Option C: Although the nurse would document the findings, the most appropriate action would be to
increase the hydration.
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?
lightheadedness and dizziness have subsided. - ✔✔Instruct the mother to request help when getting out
of bed.
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.
• Option A: 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.
Before starting the fundal assessment, the nurse should ask the mother to empty her bladder so that an
accurate assessment can be done.
• Options A and B: When the nurse is performing a fundal assessment, the nurse asks the woman to lie
flat on her back with the knees flexed.
• Option D: 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.
Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in
amount. Foul smelling or purulent lochia usually indicates infection, and these findings are not normal.
• Option A: Normal lochia has a fleshy odor.
• Options C and D: 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?
D. Encourage increased intake of fluids. - ✔✔Notify the physician.
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.
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: - ✔✔3 days PP.
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.
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: - ✔✔A and C.
In the PP period, cervical healing occurs rapidly and cervical involution occurs.
After 1 week the muscle begins to regenerate and the cervix feels firm and the external os, is the width
of a pencil. The fundus begins to descent into the pelvic cavity after 24 hours, a process known as
involution.
• Option B: 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.
• Option D: Despite blood loss that occurs during 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.
• Option E: Soon after childbirth, digestion begins to begin to be active, and the new mother is usually
hungry because of the energy expended during labor.
