Nursing 404 Exam 2 NClex Questions
With Complete Answers
Which patient would be most likely to have severe afterbirth pains and request a
narcotic analgesic?
a. Gravida 5, para 5
b. Primipara who delivered a 7-lb boy
c. Patient who is bottle feeding her first child
d. Patient who is breastfeeding her second child - ANSWER ANS: A
The discomfort of afterpains is more acute for multiparas because repeated
stretching of muscle fibers leads to loss of uterine muscle tone. The uterus of a
primipara tends to remain contracted. Afterpains are particularly severe during
breastfeeding, not bottle feeding. The non-nursing mother may have
engorgement problems that will cause her discomfort. The patient who is
nursing her second child will have more afterpains than her first pregnancy;
however, they will not be as severe as the grand multiparous patient.
Which maternal event is abnormal in the early postpartal period?
a. Diuresis and diaphoresis
b. Flatulence and constipation
c. Extreme hunger and thirst
d. Lochial color changes from rubra to alba - ANSWER ANS: D
For the first 3 days after childbirth, lochia is termed rubra. Lochia serosa
follows, and then at about 11 days, the discharge becomes clear, colorless, or
white. The body rids itself of increased plasma volume. Urine output of 3000
mL/day is common for the first few days after birth and is facilitated by hormonal
changes in the mother. Bowel tone remains sluggish for days. Many women
anticipate pain during defecation and are unwilling to exert pressure on the
perineum. The new mother is hungry because of energy used in labor and thirsty
because of fluid restrictions during labor.
Which fundal assessment finding at 12 hours after birth requires further
assessment?
a. The fundus is palpable at the level of the umbilicus.
b. The fundus is palpable two fingerbreadths above the umbilicus.
c. The fundus is palpable one fingerbreadth below the umbilicus.
,d. The fundus is palpable two fingerbreadths below the umbilicus. - ANSWER
ANS: B
The fundus rises to the umbilicus after birth and remains there for about 24
hours. A fundus that is above the umbilicus may indicate uterine atony or urinary
retention. The fundus palpable at the umbilicus is an appropriate assessment
finding for 12 hours postpartum. The fundus palpable one fingerbreadth below
the umbilicus is an appropriate assessment finding for 12 hours postpartum. The
fundus palpable two fingerbreadths below the umbilicus is an unusual finding for
12 hours postpartum; however, it is still appropriate.
If the patient's white blood cell (WBC) count is 25,000/mm3 on her second
postpartum day, which action should the nurse take?
a. Document the finding.
b. Inform the health care provider.
c. Begin antibiotic therapy immediately.
d. Have the laboratory draw blood for reanalysis. - ANSWER ANS: A
An increase in WBC count to 25,000/mm3 during the postpartum period is
considered normal and not a sign of infection. The nurse should document the
finding. There is no reason to alert the health care provider. Antibiotics are not
needed because the elevated WBCs are caused by the stress of labor and not an
infectious process. There is no need for reassessment as it is expected for the
WBCs to be elevated.
Postpartal overdistention of the bladder and urinary retention can lead to which
complication?
a. Fever and increased blood pressure
b. Postpartum hemorrhage and eclampsia
c. Urinary tract infection and uterine rupture
d. Postpartum hemorrhage and urinary tract infection - ANSWER ANS: D
Incomplete emptying and overdistention of the bladder can lead to urinary tract
infection. Overdistention of the bladder displaces the uterus and prevents
contraction of the uterine muscle. There is no correlation between bladder
distention and blood pressure or fever. There is no correlation between bladder
distention and eclampsia. The risk of uterine rupture decreases after the birth
A postpartum patient asks, "Will these stretch marks ever go away?" Which is
the nurse's best response?
a. "No, never."
b. "Yes, eventually."
c. "They will fade to silvery lines but won't disappear completely."
d. "They will continue to fade and should be gone by your 6-week checkup." -
ANSWER ANS: C
,Stretch marks never disappear altogether, but they do gradually fade to silvery
lines. Stating never is true, but more information can be added, such as the
changes that will occur with the stretch marks. Stretch marks do not disappear.
A pregnant patient asks when the dark line on her abdomen (linea nigra) will go
away. The nurse knows the pigmentation will fade after birth due to
a. increased estrogen.
b. increased progesterone.
c. decreased human placental lactogen.
d. decreased melanocyte-stimulating hormone - ANSWER ANS: D
Melanocyte-stimulating hormone increases during pregnancy and is responsible
for changes in skin pigmentation; the amount decreases after birth. Estrogen
levels decrease after birth. Progesterone levels decrease after birth. Human
placental lactogen production continues to aid in lactation. However, it does not
affect pigmentation.
Which clinical finding should the nurse suspect if the fundus is palpated on the
right side of the abdomen above the expected level?
a. Distended bladder
b. Normal involution
c. Been lying on her right side too long
d. Stretched ligaments that are unable to support the uterus - ANSWER ANS: A
The presence of a full bladder will displace the uterus. A palpated fundus on the
right side of the abdomen above the expected level is not an expected finding.
Position of the patient should not alter uterine position. The problem is a full
bladder displacing the uterus.
Which situation would require the administration of Rho(D) immune globulin?
a. Mother Rh-negative, baby Rh-positive
b. Mother Rh-negative, baby Rh-negative
c. Mother Rh-positive, baby Rh-positive
d. Mother Rh-positive, baby Rh-negative - ANSWER ANS: A
An Rh-negative mother delivering an Rh-positive baby may develop antibodies to
fetal cells that entered her bloodstream when the placenta separated. The
Rho(D) immune globulin works to destroy the fetal cells in the maternal
circulation before sensitization occurs. When the blood types are alike as with
mother Rh-negative, baby Rh-negative, no antibody formation would be
anticipated. If the Rh-positive blood of the mother comes in contact with the Rh-
negative blood of the infant, no antibodies would develop because the antigens
are in the mother's blood, not the infant's.
If the rubella vaccine is indicated for a postpartum patient, which instructions
should be provided?
, a. No specific instructions
b. Drinking plenty of fluids to prevent fever
c. Recommendation to stop breastfeeding for 24 hours after the injection
d. Explanation of the risks of becoming pregnant within 28 days following
injection - ANSWER ANS: D
Potential risks to the fetus can occur if pregnancy results within 3 months after
rubella vaccine administration. The mother does need to understand potential
side effects and that pregnancy is discouraged for 3 months. The mother should
be afebrile before the vaccine. Small amounts of the vaccine do cross the breast
milk, but it is believed that there is no need to discontinue breastfeeding.
Which measure is optimal in order to prevent abdominal distention following a
cesarean birth?
a. Rectal suppositories
b. Carbonated beverages
c. Early and frequent ambulation
d. Tightening and relaxing abdominal muscles - ANSWER ANS: C
Activity can aid the movement of accumulated gas in the gastrointestinal tract.
Rectal suppositories can be helpful after distention occurs; however, do not
prevent it. Carbonated beverages may increase distention. Ambulation is the
best prevention. Abdominal strengthening will not prevent distention.
To assess fundal contraction 6 hours after cesarean birth, which technique
should the nurse utilize?
a. Assess lochial flow rather than palpating the fundus.
b. Palpate forcefully through the abdominal dressing.
c. Place hands on both sides of the abdomen and press downward.
d. Gently palpate, applying the same technique used for vaginal deliveries. -
ANSWER ANS: D
Assessment of the fundus is the same for vaginal and cesarean deliveries.
Forceful palpation should never be used. The top of the fundus, not the sides,
should be palpated and massaged. Assessing lochial flow is not adequate; the
fundus also needs to be checked.
The nurse has completed a postpartum assessment on a patient who delivered 1
hour ago. Which amount of lochia consists of a moderate amount?
a. Saturated peripad
b. 10 to 15 cm (4- to 6-inch) stain on the peripad
c. 2.5 to 10 cm (1- to 4-inch) stain on the peripad
d. Less than a 1-inch stain on the peripad - ANSWER ANS: B
Because estimating the amount of lochia is difficult, nurses frequently record
flow by estimating the amount of lochia in 1 hour using the following labels: •
With Complete Answers
Which patient would be most likely to have severe afterbirth pains and request a
narcotic analgesic?
a. Gravida 5, para 5
b. Primipara who delivered a 7-lb boy
c. Patient who is bottle feeding her first child
d. Patient who is breastfeeding her second child - ANSWER ANS: A
The discomfort of afterpains is more acute for multiparas because repeated
stretching of muscle fibers leads to loss of uterine muscle tone. The uterus of a
primipara tends to remain contracted. Afterpains are particularly severe during
breastfeeding, not bottle feeding. The non-nursing mother may have
engorgement problems that will cause her discomfort. The patient who is
nursing her second child will have more afterpains than her first pregnancy;
however, they will not be as severe as the grand multiparous patient.
Which maternal event is abnormal in the early postpartal period?
a. Diuresis and diaphoresis
b. Flatulence and constipation
c. Extreme hunger and thirst
d. Lochial color changes from rubra to alba - ANSWER ANS: D
For the first 3 days after childbirth, lochia is termed rubra. Lochia serosa
follows, and then at about 11 days, the discharge becomes clear, colorless, or
white. The body rids itself of increased plasma volume. Urine output of 3000
mL/day is common for the first few days after birth and is facilitated by hormonal
changes in the mother. Bowel tone remains sluggish for days. Many women
anticipate pain during defecation and are unwilling to exert pressure on the
perineum. The new mother is hungry because of energy used in labor and thirsty
because of fluid restrictions during labor.
Which fundal assessment finding at 12 hours after birth requires further
assessment?
a. The fundus is palpable at the level of the umbilicus.
b. The fundus is palpable two fingerbreadths above the umbilicus.
c. The fundus is palpable one fingerbreadth below the umbilicus.
,d. The fundus is palpable two fingerbreadths below the umbilicus. - ANSWER
ANS: B
The fundus rises to the umbilicus after birth and remains there for about 24
hours. A fundus that is above the umbilicus may indicate uterine atony or urinary
retention. The fundus palpable at the umbilicus is an appropriate assessment
finding for 12 hours postpartum. The fundus palpable one fingerbreadth below
the umbilicus is an appropriate assessment finding for 12 hours postpartum. The
fundus palpable two fingerbreadths below the umbilicus is an unusual finding for
12 hours postpartum; however, it is still appropriate.
If the patient's white blood cell (WBC) count is 25,000/mm3 on her second
postpartum day, which action should the nurse take?
a. Document the finding.
b. Inform the health care provider.
c. Begin antibiotic therapy immediately.
d. Have the laboratory draw blood for reanalysis. - ANSWER ANS: A
An increase in WBC count to 25,000/mm3 during the postpartum period is
considered normal and not a sign of infection. The nurse should document the
finding. There is no reason to alert the health care provider. Antibiotics are not
needed because the elevated WBCs are caused by the stress of labor and not an
infectious process. There is no need for reassessment as it is expected for the
WBCs to be elevated.
Postpartal overdistention of the bladder and urinary retention can lead to which
complication?
a. Fever and increased blood pressure
b. Postpartum hemorrhage and eclampsia
c. Urinary tract infection and uterine rupture
d. Postpartum hemorrhage and urinary tract infection - ANSWER ANS: D
Incomplete emptying and overdistention of the bladder can lead to urinary tract
infection. Overdistention of the bladder displaces the uterus and prevents
contraction of the uterine muscle. There is no correlation between bladder
distention and blood pressure or fever. There is no correlation between bladder
distention and eclampsia. The risk of uterine rupture decreases after the birth
A postpartum patient asks, "Will these stretch marks ever go away?" Which is
the nurse's best response?
a. "No, never."
b. "Yes, eventually."
c. "They will fade to silvery lines but won't disappear completely."
d. "They will continue to fade and should be gone by your 6-week checkup." -
ANSWER ANS: C
,Stretch marks never disappear altogether, but they do gradually fade to silvery
lines. Stating never is true, but more information can be added, such as the
changes that will occur with the stretch marks. Stretch marks do not disappear.
A pregnant patient asks when the dark line on her abdomen (linea nigra) will go
away. The nurse knows the pigmentation will fade after birth due to
a. increased estrogen.
b. increased progesterone.
c. decreased human placental lactogen.
d. decreased melanocyte-stimulating hormone - ANSWER ANS: D
Melanocyte-stimulating hormone increases during pregnancy and is responsible
for changes in skin pigmentation; the amount decreases after birth. Estrogen
levels decrease after birth. Progesterone levels decrease after birth. Human
placental lactogen production continues to aid in lactation. However, it does not
affect pigmentation.
Which clinical finding should the nurse suspect if the fundus is palpated on the
right side of the abdomen above the expected level?
a. Distended bladder
b. Normal involution
c. Been lying on her right side too long
d. Stretched ligaments that are unable to support the uterus - ANSWER ANS: A
The presence of a full bladder will displace the uterus. A palpated fundus on the
right side of the abdomen above the expected level is not an expected finding.
Position of the patient should not alter uterine position. The problem is a full
bladder displacing the uterus.
Which situation would require the administration of Rho(D) immune globulin?
a. Mother Rh-negative, baby Rh-positive
b. Mother Rh-negative, baby Rh-negative
c. Mother Rh-positive, baby Rh-positive
d. Mother Rh-positive, baby Rh-negative - ANSWER ANS: A
An Rh-negative mother delivering an Rh-positive baby may develop antibodies to
fetal cells that entered her bloodstream when the placenta separated. The
Rho(D) immune globulin works to destroy the fetal cells in the maternal
circulation before sensitization occurs. When the blood types are alike as with
mother Rh-negative, baby Rh-negative, no antibody formation would be
anticipated. If the Rh-positive blood of the mother comes in contact with the Rh-
negative blood of the infant, no antibodies would develop because the antigens
are in the mother's blood, not the infant's.
If the rubella vaccine is indicated for a postpartum patient, which instructions
should be provided?
, a. No specific instructions
b. Drinking plenty of fluids to prevent fever
c. Recommendation to stop breastfeeding for 24 hours after the injection
d. Explanation of the risks of becoming pregnant within 28 days following
injection - ANSWER ANS: D
Potential risks to the fetus can occur if pregnancy results within 3 months after
rubella vaccine administration. The mother does need to understand potential
side effects and that pregnancy is discouraged for 3 months. The mother should
be afebrile before the vaccine. Small amounts of the vaccine do cross the breast
milk, but it is believed that there is no need to discontinue breastfeeding.
Which measure is optimal in order to prevent abdominal distention following a
cesarean birth?
a. Rectal suppositories
b. Carbonated beverages
c. Early and frequent ambulation
d. Tightening and relaxing abdominal muscles - ANSWER ANS: C
Activity can aid the movement of accumulated gas in the gastrointestinal tract.
Rectal suppositories can be helpful after distention occurs; however, do not
prevent it. Carbonated beverages may increase distention. Ambulation is the
best prevention. Abdominal strengthening will not prevent distention.
To assess fundal contraction 6 hours after cesarean birth, which technique
should the nurse utilize?
a. Assess lochial flow rather than palpating the fundus.
b. Palpate forcefully through the abdominal dressing.
c. Place hands on both sides of the abdomen and press downward.
d. Gently palpate, applying the same technique used for vaginal deliveries. -
ANSWER ANS: D
Assessment of the fundus is the same for vaginal and cesarean deliveries.
Forceful palpation should never be used. The top of the fundus, not the sides,
should be palpated and massaged. Assessing lochial flow is not adequate; the
fundus also needs to be checked.
The nurse has completed a postpartum assessment on a patient who delivered 1
hour ago. Which amount of lochia consists of a moderate amount?
a. Saturated peripad
b. 10 to 15 cm (4- to 6-inch) stain on the peripad
c. 2.5 to 10 cm (1- to 4-inch) stain on the peripad
d. Less than a 1-inch stain on the peripad - ANSWER ANS: B
Because estimating the amount of lochia is difficult, nurses frequently record
flow by estimating the amount of lochia in 1 hour using the following labels: •
