Questions and Answers Graded A+
A postpartum nurse is preparing to care for a woman who has just delivered a
healthy newborn infant. In the immediate postpartum period the nurse plans to take
the woman's vital signs:
Every 30 minutes during the first hour and then every hour for the next two hours.
Every 15 minutes during the first hour and then every 30 minutes for the next two
hours.
Every hour for the first 2 hours and then every 4 hours
Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours. -
Correct answer-2
A postpartum nurse is taking the vital signs of a woman who delivered a healthy
newborn infant 4 hours ago. The nurse notes that the mother's temperature is
100.2*F. Which of the following actions would be most appropriate?
©COPYRIGHT 2025, ALL RIGHTS RESERVED 1
,Retake the temperature in 15 minutes
Notify the physician
Document the findings
Increase hydration by encouraging oral fluids - Correct answer-4. The mother's
temperature may be taken every 4 hours while she is awake. Temperatures up to
100.4 (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.
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?
Obtain hemoglobin and hematocrit levels
Instruct the mother to request help when getting out of bed
Elevate the mother's legs
©COPYRIGHT 2025, ALL RIGHTS RESERVED 2
,Inform the nursery room nurse to avoid bringing the newborn infant to the mother
until the feelings of light-headedness and dizziness have subsided. - Correct
answer-2. 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 physicians
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 client to turn on her side
Ask the client to lie flat on her back with the knees and legs flat and straight.
Ask the mother to urinate and empty her bladder
Massage the fundus gently before determining the level of the fundus. - Correct
answer-3. 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 fundal assessment, the nurse asks the woman to lie flat on her back
©COPYRIGHT 2025, ALL RIGHTS RESERVED 3
, with the 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:
Normal
Indicates the presence of infection
Indicates the need for increasing oral fluids
Indicates the need for increasing ambulation - Correct answer-2. 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?
©COPYRIGHT 2025, ALL RIGHTS RESERVED 4