1.

On completing a fundal assessment, the nurse notes the fundus is situated

on the client’s left abdomen. Which of the following actions is appropriate?
A. Ask the client to empty her bladder.
B. Straight catheterize the client immediately.
C. Call the client’s health provider for direction.
D. Straight catheterize the client for half of her uterine volume.

Correct Answer: A. Ask the client to empty her bladder.

A full bladder may displace the uterine fundus to the left or right side of the
abdomen. Massage the fundus every 15 minutes during the first hour, every 30
minutes during the next hour, and then, every hour until the patient is ready for
transfer.

2. The nurse is about to give a Type 2 diabetic her insulin before breakfast on
her first day postpartum. Which of the following answers best describes
insulin requirements immediately postpartum?
A. Lower than during her pregnancy
B. Higher than during her pregnancy
C. Lower than before she became pregnant
D. Higher than before she became pregnant

Correct Answer: C. Lower than before she became pregnant

PP insulin requirements are usually significantly lower than pre-pregnancy
requirements. Occasionally, clients may require little to no insulin during the first
24 to 48 hours postpartum. Immediately after delivery, postpartum insulin
requirements decrease dramatically as a result of the rapid decrease in
diabetogenic placental hormone levels and resulting dissipation of pregnancy-
induced insulin resistance.

3. Which of the following findings would be expected when assessing the

postpartum client?
A. Fundus 1 cm above the umbilicus 1 hour postpartum.
B. Fundus 1 cm above the umbilicus on a postpartum day 3.
C. Fundus palpable in the abdomen at 2 weeks postpartum.
D. Fundus slightly to the right; 2 cm above umbilicus on postpartum day 2.
Correct Answer: A. Fundus 1 cm above the umbilicus 1 hour postpartum.
Within the first 12 hours postpartum, the fundus usually is approximately 1 cm
above the umbilicus. Immediately postpartum, the uterine fundus is palpable at
or near the level of the maternal umbilicus. If the fundus is found above the
navel, the mother probably needs to pass urine. Call a midwife if the uterus feels
soft or is not descending.

4. A client is complaining of painful contractions, or after pains, on

postpartum day 2. Which of the following conditions would increase the
severity of afterpains?
A. Bottle-feeding
B. Diabetes
C. Multiple gestation
D. Primiparity

Correct Answer: C. Multiple gestation

Multiple gestation, multiparity, and conditions that cause overdistention of the
uterus will increase the intensity of after-pains. Afterpain is a common
phenomenon after vaginal delivery. Any factor that causes a delay in the process
of uterus sub involution and consequently returning its size to pre-pregnancy
status could affect the severity of afterpain.

5. On which of the postpartum days can the client expect lochia serosa?
A. Days 3 and 4 PP
B. Days 3 to 10 PP
C. Days 10-14 PP
D. Days 14 to 42 PP

Correct Answer: B. Days 3 to 10 PP.

On the third and fourth PP days, the lochia becomes a pale pink or brown and
contains old blood, serum, leukocytes, and tissue debris. This type of lochia
usually lasts until PP day 10. The mother might notice increased lochia when she
gets up in the morning when she is physically active, or while breastfeeding.
Moms who have cesarean sections may have less lochia after 24 hours than
moms who had vaginal deliveries. The bleeding generally stops within 4 to 6
weeks after delivery. The mother should wear pads, not tampons, as nothing
should go in the vagina for six weeks.

6. Which of the following behaviors characterizes the PP mother in the taking

in phase?
A. Passive and dependent
B. Striving for independence and autonomy
C. Curious and interested in care of the baby
D. Exhibiting maximum readiness for new learning

Correct Answer: A. Passive and dependent

During the taking in phase, which usually lasts 1-3 days, the mother is passive
and dependent and expresses her own needs rather than the neonate’s needs.
The woman becomes dependent on her healthcare provider or support person
with some of the daily tasks and decision-making. This dependence is mainly due
to her physical discomfort from hemorrhoids or the after pains, from the
uncertainty of how she could care for the newborn, and also from the extreme
tiredness she feels that follows childbirth.

7. Which of the following complications may be indicated by continuous

seepage of blood from the vagina of a PP client, when palpation of the
uterus reveals a firm uterus 1 cm below the umbilicus?
A. Uterine atony
B. Cervical laceration
C. Urinary tract infection
D. Retained placental fragments

Correct Answer: B. Cervical laceration

Continuous seepage of blood may be due to cervical or vaginal lacerations if the
uterus is firm and contracting. Cervical lacerations (CL) are a known cause of
postpartum hemorrhage. Although CL occurs in more than half of vaginal
deliveries,1 they are less than 0.5 cm in length and rarely require repair.
 8. What type of milk is present in the breasts 7 to 10 days PP?
A. Colostrum
B. Transitional milk
C. Mature milk
D. Hind milk

Correct Answer: B. Transitional milk

Transitional milk comes after colostrum and usually lasts until 2 weeks PP. When
breastfeeding mothers talk about their milk coming in, they are referring to the
onset of production of transitional milk, the creamy milk that immediately follows
colostrum. Transitional milk is produced anywhere from about two to five days
after birth until ten to fourteen days after birth.

9. Which of the following complications is most likely responsible for a

delayed postpartum hemorrhage?
A. Uterine subinvolution
B. Clotting deficiency
C. Perineal laceration
D. Cervical laceration

Correct Answer: A. Uterine subinvolution

Late postpartum bleeding is often the result of subinvolution of the uterus.
Retained products of conception or infection often cause subinvolution. Delayed
postpartum bleeding should always raise the possibility of subinvolution.
Although subinvolution may cause bleeding anytime between 1 week and several
months postpartum, the most common reported timeline for presentation is
within the second week after delivery.

10. Before giving a postpartum (PP) client the rubella vaccine, which of the
following facts should the nurse include in client teaching?
A. The vaccine is safe in clients with egg allergies.
B. Breastfeeding isn’t compatible with the vaccine.
C. Transient arthralgia and rash are common adverse effects.
D. The client should avoid getting pregnant for 3 months after the vaccine
because the vaccine has teratogenic effects.
Correct Answer: D. The client should avoid getting pregnant for 3 months
after the vaccine because the vaccine has teratogenic effects.
The client must understand that she must not become pregnant for 3 months
after the vaccination because of its potential teratogenic effects. Women who are
planning to become pregnant should check with their doctor to make sure they
are vaccinated before they get pregnant. Because MMR vaccine is an attenuated
(weakened) live virus vaccine, pregnant women who are not vaccinated should
wait to get MMR vaccine until after they have given birth. Adult women of
childbearing age should avoid getting pregnant for at least four weeks after
receiving an MMR vaccine.

11. Which of the following changes A. Increase described the insulin needs of a
client with type 1 diabetes who has just delivered an infant vaginally
without complications?
A. Increase
B. Decrease
C. Remain the same as before pregnancy
D. Remain the same as during pregnancy

Correct Answer: B. Decrease.

The placenta produces the hormone human placental lactogen, an insulin
antagonist. After birth, the placenta, the major source of insulin resistance, is
gone. Insulin needs decrease and women with type 1 diabetes may only need
one-half to two-thirds of the prenatal insulin during the first few PP days.

12. Which of the following responses is most appropriate for a mother with
diabetes who wants to breastfeed her infant but is concerned about the
effects of breastfeeding on her health?
A. Mothers with diabetes who breastfeed have a hard time controlling their
insulin needs.
B. Mothers with diabetes shouldn’t breastfeed because of potential
complications.
C. Mothers with diabetes shouldn’t breastfeed; insulin requirements are
doubled.
 D. Mothers with diabetes may breastfeed; insulin requirements may
decrease from breastfeeding.

Correct Answer: D. Mothers with diabetes may breastfeed; insulin

requirements may decrease from breastfeeding.
Breastfeeding has an antidiabetogenic effect. Insulin needs are decreased
because carbohydrates are used in milk production. Breastfeeding mothers are at
a higher risk of hypoglycemia in the first PP days after birth because the glucose
levels are lower. Mothers with diabetes should be encouraged to breastfeed.

13. On the first postpartum (PP) night, a client requests that her baby be sent
back to the nursery so she can get some sleep. The client is most likely in
which of the following phases?
A. Depression phase
B. Letting-go phase
C. Taking-hold phase
D. Taking-in phase

Correct Answer: D. Taking-in phase

The taking-in phase occurs in the first 24 hours after birth. The mother is
concerned with her own needs and requires support from staff and relatives. The
woman becomes dependent on her healthcare provider or support person with
some of the daily tasks and decision-making. The woman prefers to talk about
her experiences during labor and birth and also her pregnancy. Encouraging the
woman to talk about her experiences during labor and birth would greatly help
her adjust and let her incorporate it into her new life.

14. Which of the following physiological responses is considered normal in the

early postpartum period?
A. Urinary urgency and dysuria
B. Rapid diuresis
C. Decrease in blood pressure
D. Increase motility of the GI system

Correct Answer: B. Rapid diuresis

In the early PP period, there’s an increase in the glomerular filtration rate and a
drop in the progesterone levels, which result in rapid diuresis. During pregnancy,
the compressive forces of the gravid uterus and the progesterone-induced
decrease in ureteral tone, peristalsis, and contraction pressure lead to the dilation
of the calyceal system, increasing the volume of kidneys by 30% from the pre-
pregnant state. The dilated ureters and renal pelvis usually return to the pre-
pregnant state within four-eight weeks.

15. During the 3rd PP day, which of the following observations about the
client would the nurse be most likely to make?
A. The client appears interested in learning about neonatal care.
B. The client talks a lot about her birth experience.
C. The client sleeps whenever the neonate isn’t present.
D. The client requests help in choosing a name for the neonate.

Correct Answer: A. The client appears interested in learning about neonatal

care.
The third to tenth days of PP care are the “taking-hold” phase, in which the new
mother strives for independence and is eager for her neonate. The woman starts
to initiate actions on her own and makes decisions without relying on others. She
starts to focus on the newborn instead of herself and begins to actively
participate in newborn care. The other options describe th

16. Which of the following circumstances is most likely to cause uterine atony
and lead to PP hemorrhage?
A. Hypertension
B. Cervical and vaginal tears
C. Urine retention
D. Endometritis

Correct Answer: C. Urine retention.

Urine retention causes a distended bladder to displace the uterus above the
umbilicus and to the side, which prevents the uterus from contracting. The uterus
needs to remain contracted if bleeding is to stay within normal limits. Cervical
and vaginal tears can cause PP hemorrhage but are less common occurrences in
the PP period.
 17. Which type of lochia should the nurse expect to find in a client 2 days PP?
A. Foul-smelling
B. Lochia serosa
C. Lochia alba
D. Lochia rubra

Correct Answer: D. Lochia rubra

Lochia, also known as postpartum bleeding, is a normal discharge of blood and
mucus from the uterus after childbirth. It begins right after delivery and can
continue for four to six weeks postpartum, with the heaviest flow occurring for
the first 10 to 14 days. Some women may have a shorter period of discharge,
while others may have lochia for slightly longer than four to six weeks. At first,
lochia will look dark red and the flow may be heavy. This is called lochia rubra.
The lochia is initially red and comprised of blood and fragments of decidua,
endometrial tissues, and mucus and lasts 1 to 4 days.

18. fter the expulsion of the placenta in a client who has six living children, an
infusion of lactated ringer’s solution with 10 units of Pitocin is ordered. The
nurse understands that this is indicated for this client because:
A. She had a precipitate birth
B. This was an extramural birth
C. Retained placental fragments must be expelled
D. Multigravidae are at increased risk for uterine atony

Correct Answer: D. Multigravidas are at increased risk for uterine atony.

Multiple full-term pregnancies and deliveries result in overstretched uterine
muscles that do not contract efficiently and bleeding may ensue. Risk factors for
uterine atony include prolonged labor, precipitous labor, uterine distension
(multifetal gestation, polyhydramnios, fetal macrosomia), fibroid uterus,
chorioamnionitis, indicated magnesium sulfate infusions, and prolonged use of
oxytocin.
 19. As part of the postpartum assessment, the nurse examines the breasts of a
primiparous breastfeeding woman who is one day postpartum. An
expected finding would be:
A. Soft, non-tender; colostrum is present.
B. Leakage of milk at let down.
C. Swollen, warm, and tender upon palpation.
D. A few blisters and a bruise on each areola.

Correct Answer: A. Soft, non-tender; colostrum is present.

Breasts are essentially unchanged for the first two to three days after birth.
Colostrum is present and may leak from the nipples. There are distinct stages
seen in milk production which start before the birth of the baby. The first milk is
colostrum which is available after labor. Occasionally, there is pre-colostrum
before the postpartum stage. Colostrum is high in protein, sodium, and
immunoglobulins while being low in lactose, and this is the first milk produced
for the baby. After 30 to 40 hours postpartum, the milk composition changes by
an increase of lactose and dilution of other constituents as the volume increases.

20. Following the birth of her baby, a woman expresses concern about the
weight she gained during pregnancy and how quickly she can lose it now
that the baby is born. The nurse, in describing the expected pattern of
weight loss, should begin by telling this woman that:
A. Return to pre-pregnant weight is usually achieved by the end of the
postpartum period
B. Fluid loss from diuresis, diaphoresis, and bleeding accounts for about a
3-pound weight loss.
C. The expected weight loss immediately after birth averages about 11 to
13 pounds.
D. Lactation will inhibit weight loss since caloric intake must increase to
support milk production.

Correct Answer: C. The expected weight loss immediately after birth

averages about 11 to 13 pounds.
The woman should plan to return to pre-pregnancy weight by 6 to 12 months
after delivery. Most women lose half of their baby weight by 6 weeks after
childbirth (postpartum). The rest most often comes off over the next several
months. The body needs time to recover from childbirth. If the woman loses
weight too soon after childbirth, it can take longer for her to recover. She should
give herself until the 6-week checkup before trying to slim down.

21. Which of the following findings would be a source of concern if noted

during the assessment of a woman who is 12 hours postpartum?
A. Postural hypotension
B. Temperature of 100.4°F
C. Bradycardia — pulse rate of 55 BPM
D. Pain in left calf with dorsiflexion of the left foot

Correct Answer: D. Pain in left calf with dorsiflexion of the left foot.
Pain in the left calf with dorsiflexion of the left foot indicates a positive Homan
sign and is suggestive of thrombophlebitis and should be investigated further.
The risk of developing blood clots (thrombophlebitis) is increased for about 6 to
8 weeks after delivery . Typically, blood clots occur in the deep veins of the legs
or pelvis (a disorder called deep vein thrombosis). Sometimes one of these clots
breaks loose and travels through the bloodstream into the lungs, where it lodges
in a blood vessel in the lung, blocking blood flow. This blockage is called
pulmonary embolism. Blood clots may also develop in the veins just under the
skin in the legs. This disorder is called superficial venous thrombosis (superficial
thrombophlebitis).

22. The nurse examines a woman one hour after birth. The woman’s fundus is
boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse,
with two plum-sized clots. The nurse’s initial action would be to:
A. Place her on a bedpan to empty her bladder.
B. Massage her fundus
C. Call the physician
D. Administer Methergine 0.2 mg IM which has been ordered prn.

Correct Answer: B. Massage her fundus

A boggy or soft fundus indicates that uterine atony is present. If uterine atony
occurs, healthcare providers should be ready for initial medical management
which is directed to the use of medications to improve tone and induce uterine
contractions. Massaging the uterus is also effective, as is ensuring an empty
cavity. This is confirmed by the profuse lochia and passage of clots. The first
action would be to massage the fundus until firm, followed by options C and D,
especially if the fundus does not become or remain firm with massage.

23. When performing a postpartum check, the nurse should:

A. Assist the woman into a lateral position with upper leg flexed forward to
facilitate the examination of her perineum.
B. Assist the woman into a supine position with her arms above her head
and her legs extended for the examination of her abdomen.
C. Instruct the woman to avoid urinating just before the examination since
a full bladder will facilitate fundal palpation.
D. Wash hands and put on sterile gloves before beginning the check.

Correct Answer: A. Assist the woman into a lateral position with upper leg
flexed forward to facilitate the examination of her perineum.
While the supine position is best for examining the abdomen, the woman should
keep her arms at her sides and slightly flex her knees in order to relax abdominal
muscles and facilitate palpation of the fundus. The nurse must be well versed in
postpartum assessment and be able to identify subtle changes that could
indicate a woman’s deteriorating condition. Components of care should be
standardized regardless of whether the recovery is done in a post-anesthesia care
unit (PACU), a labor and delivery room, or a postpartum room

24. Perineal care is an important infection control measure. When evaluating a

postpartum woman’s perineal care technique, the nurse would recognize
the need for further instruction if the woman:
A. Uses soap and warm water to wash the vulva and perineum.
B. Washes from symphysis pubis back to episiotomy.
C. Changes her perineal pad every 2 – 3 hours.
D. Uses the peri bottle to rinse upward into her vagina.

Correct Answer: D. Uses the peri bottle to rinse upward into her vagina.
The peri bottle should be used in a backward direction over the perineum. The
flow should never be directed upward into the vagina since debris would be
forced upward into the uterus through the still-open cervix. Rinse perineum with
water after using the toilet and before the woman puts on a new peri-pad.
Caregivers will show how to use a peri-bottle (hand-held squirt bottle) to rinse
the perineum. Squirting warm tap water on the perineum will keep it clean and
may provide comfort for pain. While sitting on the toilet, the woman should rinse
the perineum. She should aim the bottle opening at her perineum and spray so
the water moves from front to back.
25. Which measure would be least effective in preventing postpartum
hemorrhage?
A. Administer Methergine 0.2 mg every 6 hours for 4 doses as ordered.
B. Encourage the woman to void every 2 hours.
C. Massage the fundus every hour for the first 24 hours following birth.
D. Teach the woman the importance of rest and nutrition to enhance
healing.

Correct Answer: C. Massage the fundus every hour for the first 24 hours
following birth.
The fundus should be massaged only when boggy or soft. Massaging a firm
fundus could cause it to relax. Uterine atony refers to the corpus uteri myometrial
cells inadequate contraction in response to endogenous oxytocin that is released
in the course of delivery. It leads to postpartum hemorrhage as delivery of the
placenta leaves disrupted spiral arteries which are uniquely void of musculature
and dependent on contractions to mechanically squeeze them into a hemostatic
state.