Postpartum NCLEX Exam Questions
And Answers||
The nurse is caring for a client during the immediate recovery phase or fourth stage of
labor. Which action is most important for the nurse to take at this time? -CORRECT
ANSWER Check the uterine fundus and lochia.
The postpartum nurse is caring for a mother following delivery of a newborn infant. The
nurse performs a perineal assessment on the mother and notes a trickle of bright red
blood coming from the perineum. The nurse checks the mother's fundus and notes that
it is firm. On review of the mother's record, the nurse also notes that an episiotomy was
performed. Which determination should the nurse make based on this information? -
CORRECT ANSWER The bright red bleeding is abnormal and should be reported.
The nurse provides instructions to a breastfeeding mother who is experiencing breast
engorgement about measures that will provide comfort. Which statement by the mother
indicates an understanding of these measures? -CORRECT ANSWER "I will massage
the breasts before feeding to stimulate let-down."
Which action, if noted in the new mother, indicates the need for further data collection
by the nurse for signs of postpartum depression? -CORRECT ANSWER The mother
constantly complains of tiredness and fatigue.
The nurse is reinforcing instructions to the mother following delivery regarding care of
the episiotomy site to prevent infection. Which statement by the mother indicates a need
for further teaching? -CORRECT ANSWER I will change the perineum pads three times
a day."
A client has had a midline episiotomy. In relation to clients with other types of
episiotomies, the nurse anticipates that the client will generally experience which
findings? Select all that apply. -CORRECT ANSWER Less pain
Less blood loss
More likely to extend with birth of LGA infant
The nurse is caring for a client who is being treated with antibiotics for mastitis. To
reinforce instructions, what does the nurse tell the client? -CORRECT ANSWER To
complete the entire antibiotic regimen
A new mother is seen in a health care clinic 2 weeks after giving birth to a healthy
newborn infant. The mother is complaining that she feels as though she has the flu and
complains of fatigue and aching muscles. On further assessment, the nurse notes a
localized area of redness on the left breast, and the mother is diagnosed with mastitis.
The mother asks the nurse about the condition. The nurse should make which
,response? -CORRECT ANSWER "Mastitis can occur at any time during breast-
feeding."
Mastitis is an infection of the lactating breasts and occurs most often during the second
and third weeks after birth, although it may develop at any time during breast-feeding.
Mastitis is more common in mothers who are nursing for the first time and usually
affects 1 breast only. A supportive bra will not cause mastitis; however, constriction of
the breasts from a bra that is too tight may interfere with the emptying of all ducts and
may lead to infection.
A 45-year-old woman delivered her first baby by cesarean section 5 days ago. The
postpartum recovery has been complicated by thrombophlebitis in her left leg. She cries
frequently and requests to have her newborn infant stay in the nursery. The nurse
recognizes that the mother may have intensified "postpartum blues" because of which
situation? -CORRECT ANSWER The client is required to stay on bed rest.
The nurse is caring for a client with placenta previa who is at high risk for infection and
hemorrhage. The nurse plans care based on which information related to the condition?
-CORRECT ANSWER Fewer muscle fibers in the lower segment of the uterus will result
in poor contractions.
The nurse who is caring for a postpartum mother being tested for endometritis notes
that the client has little interest in caring for her infant. Which intervention should best
facilitate the client's participation in infant care? -CORRECT ANSWER Encouraging the
client to take pain medication as prescribed
Oxytocin is administered to a client following the delivery of the placenta. The nurse
assisting in caring for the client monitors for which effectiveresponse from the
medication? -CORRECT ANSWER Uterine contractions
The nurse is monitoring a client at risk for postpartum endometritis. Which observation
noted during the first 24 hours after delivery supports this diagnosis? -CORRECT
ANSWER Abdominal tenderness and chills
The nurse has a prescription to give a dose of Rho(D) immune globulin to a client who
has delivered an infant. Which criteria need to be met in order to administer this
medication? Select all that apply. -CORRECT ANSWER Rh negative mother
Negative Coombs' test
The nurse is checking the lochia discharge on a 1-day postpartum woman. The nurse
notes that the lochia is red and has a foul odor. The nurse determines that this finding
indicates which? -CORRECT ANSWER The presence of infection
The nurse is adding to a plan of care for a postpartum client. Which intervention should
promote parent-infant bonding -CORRECT ANSWER Encourage her to hold the infant
even when the infant is crying
, After surgical evacuation and repair of a vaginal hematoma, a 3-day postpartum mother
is discharged. The nurse determines that the mother needs further teaching if the new
mother makes which statement? -CORRECT ANSWER The only medications that I will
take are prenatal vitamins and stool softeners."
The nurse palpates the fundus and checks the character of the lochia of a postpartum
client who is in the fourth stage of labor. Which lochia characteristic should the nurse
expect to note? -CORRECT ANSWER Red
The nurse is about to reinforce discharge instructions to a postpartum client who
delivered a healthy newborn infant. The occurrence of which event should be reported
to the primary health care provider? -CORRECT ANSWER Pain, redness, or swelling in
the breasts
The nurse in the postpartum unit notes that the result of a rubella titer drawn on a
postpartum client during the antepartum period is 1.8. Which should the nurse anticipate
to be prescribed by the primary health care provider? -CORRECT ANSWER
Administration of a subcutaneous rubella virus vaccine
The nurse is assisting in developing a plan of care for a client preparing to breastfeed.
In planning care, which factor is most significant in teaching a client to breastfeed? -
CORRECT ANSWER A positive nurse-client relationship
The new breastfeeding mother has been seen in the clinic for the treatment of mastitis.
Which comment by the mother indicates a need for further teaching? -CORRECT
ANSWER My left breast is sore, so I will offer only my right breast frequently for
breastfeeding."
The nurse is monitoring a new mother in the fourth stage of labor for signs of
hemorrhage. Which sign noted in the mother indicates an early sign of excessive blood
loss and shock? -CORRECT ANSWER An increase in the pulse rate from 88 to 102
beats per minute
Rho(D) immune globulin is prescribed for a client after delivery of a full-term infant.
Before administering the medication, the nurse reviews the client's history, recognizing
which circumstance as a contraindication for administering this medication? -CORRECT
ANSWER Experiencing a severe reaction to prior administered human globulin
The nurse in the newborn nursery is collecting data on a neonate who was born of a
mother addicted to cocaine. Which signs/symptoms should the nurse expect to note in
the neonate? Select all that apply. -CORRECT ANSWER Tremors
Irritability
Hypertension
Exaggerated startle reflex
And Answers||
The nurse is caring for a client during the immediate recovery phase or fourth stage of
labor. Which action is most important for the nurse to take at this time? -CORRECT
ANSWER Check the uterine fundus and lochia.
The postpartum nurse is caring for a mother following delivery of a newborn infant. The
nurse performs a perineal assessment on the mother and notes a trickle of bright red
blood coming from the perineum. The nurse checks the mother's fundus and notes that
it is firm. On review of the mother's record, the nurse also notes that an episiotomy was
performed. Which determination should the nurse make based on this information? -
CORRECT ANSWER The bright red bleeding is abnormal and should be reported.
The nurse provides instructions to a breastfeeding mother who is experiencing breast
engorgement about measures that will provide comfort. Which statement by the mother
indicates an understanding of these measures? -CORRECT ANSWER "I will massage
the breasts before feeding to stimulate let-down."
Which action, if noted in the new mother, indicates the need for further data collection
by the nurse for signs of postpartum depression? -CORRECT ANSWER The mother
constantly complains of tiredness and fatigue.
The nurse is reinforcing instructions to the mother following delivery regarding care of
the episiotomy site to prevent infection. Which statement by the mother indicates a need
for further teaching? -CORRECT ANSWER I will change the perineum pads three times
a day."
A client has had a midline episiotomy. In relation to clients with other types of
episiotomies, the nurse anticipates that the client will generally experience which
findings? Select all that apply. -CORRECT ANSWER Less pain
Less blood loss
More likely to extend with birth of LGA infant
The nurse is caring for a client who is being treated with antibiotics for mastitis. To
reinforce instructions, what does the nurse tell the client? -CORRECT ANSWER To
complete the entire antibiotic regimen
A new mother is seen in a health care clinic 2 weeks after giving birth to a healthy
newborn infant. The mother is complaining that she feels as though she has the flu and
complains of fatigue and aching muscles. On further assessment, the nurse notes a
localized area of redness on the left breast, and the mother is diagnosed with mastitis.
The mother asks the nurse about the condition. The nurse should make which
,response? -CORRECT ANSWER "Mastitis can occur at any time during breast-
feeding."
Mastitis is an infection of the lactating breasts and occurs most often during the second
and third weeks after birth, although it may develop at any time during breast-feeding.
Mastitis is more common in mothers who are nursing for the first time and usually
affects 1 breast only. A supportive bra will not cause mastitis; however, constriction of
the breasts from a bra that is too tight may interfere with the emptying of all ducts and
may lead to infection.
A 45-year-old woman delivered her first baby by cesarean section 5 days ago. The
postpartum recovery has been complicated by thrombophlebitis in her left leg. She cries
frequently and requests to have her newborn infant stay in the nursery. The nurse
recognizes that the mother may have intensified "postpartum blues" because of which
situation? -CORRECT ANSWER The client is required to stay on bed rest.
The nurse is caring for a client with placenta previa who is at high risk for infection and
hemorrhage. The nurse plans care based on which information related to the condition?
-CORRECT ANSWER Fewer muscle fibers in the lower segment of the uterus will result
in poor contractions.
The nurse who is caring for a postpartum mother being tested for endometritis notes
that the client has little interest in caring for her infant. Which intervention should best
facilitate the client's participation in infant care? -CORRECT ANSWER Encouraging the
client to take pain medication as prescribed
Oxytocin is administered to a client following the delivery of the placenta. The nurse
assisting in caring for the client monitors for which effectiveresponse from the
medication? -CORRECT ANSWER Uterine contractions
The nurse is monitoring a client at risk for postpartum endometritis. Which observation
noted during the first 24 hours after delivery supports this diagnosis? -CORRECT
ANSWER Abdominal tenderness and chills
The nurse has a prescription to give a dose of Rho(D) immune globulin to a client who
has delivered an infant. Which criteria need to be met in order to administer this
medication? Select all that apply. -CORRECT ANSWER Rh negative mother
Negative Coombs' test
The nurse is checking the lochia discharge on a 1-day postpartum woman. The nurse
notes that the lochia is red and has a foul odor. The nurse determines that this finding
indicates which? -CORRECT ANSWER The presence of infection
The nurse is adding to a plan of care for a postpartum client. Which intervention should
promote parent-infant bonding -CORRECT ANSWER Encourage her to hold the infant
even when the infant is crying
, After surgical evacuation and repair of a vaginal hematoma, a 3-day postpartum mother
is discharged. The nurse determines that the mother needs further teaching if the new
mother makes which statement? -CORRECT ANSWER The only medications that I will
take are prenatal vitamins and stool softeners."
The nurse palpates the fundus and checks the character of the lochia of a postpartum
client who is in the fourth stage of labor. Which lochia characteristic should the nurse
expect to note? -CORRECT ANSWER Red
The nurse is about to reinforce discharge instructions to a postpartum client who
delivered a healthy newborn infant. The occurrence of which event should be reported
to the primary health care provider? -CORRECT ANSWER Pain, redness, or swelling in
the breasts
The nurse in the postpartum unit notes that the result of a rubella titer drawn on a
postpartum client during the antepartum period is 1.8. Which should the nurse anticipate
to be prescribed by the primary health care provider? -CORRECT ANSWER
Administration of a subcutaneous rubella virus vaccine
The nurse is assisting in developing a plan of care for a client preparing to breastfeed.
In planning care, which factor is most significant in teaching a client to breastfeed? -
CORRECT ANSWER A positive nurse-client relationship
The new breastfeeding mother has been seen in the clinic for the treatment of mastitis.
Which comment by the mother indicates a need for further teaching? -CORRECT
ANSWER My left breast is sore, so I will offer only my right breast frequently for
breastfeeding."
The nurse is monitoring a new mother in the fourth stage of labor for signs of
hemorrhage. Which sign noted in the mother indicates an early sign of excessive blood
loss and shock? -CORRECT ANSWER An increase in the pulse rate from 88 to 102
beats per minute
Rho(D) immune globulin is prescribed for a client after delivery of a full-term infant.
Before administering the medication, the nurse reviews the client's history, recognizing
which circumstance as a contraindication for administering this medication? -CORRECT
ANSWER Experiencing a severe reaction to prior administered human globulin
The nurse in the newborn nursery is collecting data on a neonate who was born of a
mother addicted to cocaine. Which signs/symptoms should the nurse expect to note in
the neonate? Select all that apply. -CORRECT ANSWER Tremors
Irritability
Hypertension
Exaggerated startle reflex
