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NCLEX - Postpartum Care Exam
Questions with Verified Answers| Latest
Update
A 25 year-old woman gave birth to her second child 6 hours ago. She informs the nurse that she is bleeding more than with her previous birth experience. The initial nursing action is to: a. Explain that this is normal for second-time moms. b. Assess the location and firmness of the fundus. c. Change her pad and return in 1 hour and reassess. d. Give her 10 units of oxytocin as per standing order. - Answer -ANS: b a. The nurse should not inform the patient that this is normal until she has assessed for the degree and potential cause of bleeding. b. It is important to first assess for uterine atony or displaced uterus from full bladder. c. If the uterus is firm and midline, then the nurse should change the pad and return within 30 minutes to assess the amount of lochia. d. The nurse would give oxytocin if the uterus is boggy and does not respond to uterine massage. Which of these medications is commonly used to control postpartum bleeding related to uterine atony? a. Magnesium sulfate
b. Phytonadione c. Oxytocin d. Warfarin - Answer -ANS: c a. Magnesium sulfate is commonly used for PIH and preterm labor. It is a smooth muscle relaxant and can cause the uterus to relax. b. Phytonadione (vitamin K) is important for clotting but will not cause the uterus to contract. c. Oxytocin is commonly used to control postpartum bleeding related to uterine atony. d. Warfarin is an anticoagulant and will increase the risk of hemorrhage. During a postpartum assessment, the nurse notes that the uterus is midline and boggy. The immediate nursing action is: a. To notify the patients midwife or physician b. Massage the fundus until firm and reevaluate within 30 minutes c. Give Syntocinon as per orders d. Assist the patient to the bathroom and ask her to void - Answer -ANS: b a. If the uterus does not respond to massage, then the nurse would give Syntocinon and notify the primary health provider. b. The first nursing action for a boggy uterus is to massage the fundus.
b. RhoGam should be given no matter how old the fetus was. c. RhoGam must be administered before 72 hours postpartum. d. RhoGam is contraindicated for clients who are Rh+ (positive). The nurse must confirm that any client receiving RhoGam is Rh negative. A nurse is performing a postpartum assessment 30 minutes after a vaginal delivery. Which of the following actions indicates that the nurse is performing the assessment correctly? a. The nurse measures the fundal height in relation to the symphysis pubis. b. The nurse monitors the clients central venous pressure. c. The nurse assesses the clients perineum for edema and ecchymoses. d. The nurse performs a sterile vaginal speculum exam. - Answer -ANS: c a. The fundal height should be measured in relation to the umbilicus. b. The central venous pressure is not monitored during postpartum assessments. c. The nurse should assess the perineum for signs of edema and ecchymoses. d. If a speculum exam were needed, a physician or midwife would perform the procedure. Speculum exams are rarely needed postpartum.
A woman is 2 days postpartum from a normal vaginal delivery over an intact perineum of a 3000-gram baby. Where would the nurse expect to palpate the clients fundus? a. At the umbilicus b. 2 cm below the umbilicus c. 2 cm above the symphysis d. At the symphysis - Answer -ANS: b a. Expected location for 6 to 12 hours postpartum. b. The firm fundus should be 2 cm below the umbilicus. c. This is an abnormal finding and may be related to subinvolution of the uterus. d. Expected location for 6 days postpartum. Which of the following clients is most likely to complain of afterbirth pains during her postpartum period? a. G1 P0, diagnosed with preeclampsia b. G2 P0, group B streptococci in the vagina c. G3 P2, gave birth to a 4100-gram baby d. G4 P1, diagnosed with preterm labor - Answer -ANS: c a. This client is a primipara. The nurse would not expect her to complain excessively of afterbirth pains. b. This client is a primipara. The nurse would not expect her to complain excessively of afterbirth pains. c. This client is a multipara and she delivered a macrosomic baby. She is likely to complain of severe afterbirth pains.
b. Contraceptive patch c. Bilateral tubal ligation d. Birth control pills - Answer -ANS: a a. An intrauterine device (IUD) is an excellent contraceptive method for women who have had at least one delivery, are in a monogamous relationship, and wish to have long-term contraception. b. The contraceptive patch is not recommended for women over 35 or for women who smoke. c. A bilateral tubal ligation is a sterilization procedure. d. Birth control pills are not recommended for women over 35 or for women who smoke. The perinatal nurse demonstrates for the student nurse the correct technique of postpartum uterine palpation. Support for the lower uterine segment is critical, as without it, there is an increased risk of: a. Uterine edema b. Uterine inversion c. Incorrect measurement d. Intensifying the patients level of pain - Answer -ANS: b a. Placing the hand over the base of the uterus does not cause uterine edema. b. The uterine fundus is palpated by placing one hand on the base of the uterus immediately above the symphysis pubis and the other hand at the level of the umbilicus. The nurse presses inward and downward with the hand positioned on the umbilicus until the fundus is located. It
should feel like a firm, globular mass located at or slightly above the umbilicus during the first hour after birth. The uterus should never be palpated without supporting the lower uterine segment. Failure to do so may result in uterine inversion and hemorrhage. c. Measurement is the same with or without the hand supporting the lower uterine segment. d. Not supporting the lower uterine segment has no effect on the level of pain felt by the patient. Maddy, a G3 P1 woman, gave birth 12 hours ago to a 9 lb. 13 oz. daughter. She experiences severe cramps with breastfeeding. The perinatal nurse best describes this condition as: a. Afterpains b. Uterine hypertonia c. Bladder hypertonia d. Rectus abdominis diastasis - Answer -ANS: A - Afterpains (afterbirth pains) are intermittent uterine contractions that occur during the process of involution. Afterpains are more pronounced in patients with decreased uterine tone due to overdistension, which is associated with multiparity and macrosomia. Patients often describe the sensation as a discomfort similar to menstrual cramps. A 35-year-old G1 P0 postpartum woman is Rh0(D)- negative and needs Rh0(D) immune globulin to be administered. The most appropriate dose that the perinatal nurse would expect to be ordered would be:
d. Ask Heather where she is experiencing this headache and to identify the pain score that best describes the intensity of the pain. - Answer -ANS: d - The nurse should perform routine, comprehensive pain assessments to include onset, location, intensity, quality, characteristics, and aggravating and alleviating factors of the discomfort in order to provide interventions in a timely manner and enhance effectiveness of medications. The nurse should also ask the patient to rate her pain on a standard 0 to 10 pain scale before and after interventions and to identify her own acceptable comfort level on the scale. The perinatal nurse teaches the postpartum woman about the normal process of diuresis that she can expect to occur approximately 6 to 8 hours after birth. A decrease in which of the following hormones is primarily responsible for the diuresis? a. Prolactin b. Progesterone c. Oxytocin d. Estrogen - Answer -ANS: d - Maternal diuresis occurs almost immediately after birth and urinary output reaches up to 3000 mL each day by the second to fifth postpartum days. After childbirth, a decrease in the level of estrogen naturally occurs and contributes to the diuresis. During change of shift report, the nurse hears the following information on a newly delivered client: 27 years old, married, G4 P3, 8 hours postspontaneous vaginal delivery over 3 laceration, vitals110/70, 98.6F, 82, 18, fundus firm
at umbilicus, moderate lochia, ambulated to bathroom to void three times for a total of 900 mL, breastfeeding every 2 hours. Which of the following nursing diagnoses should the nurse include in this clients nursing care plan? a. Fluid volume deficit b. Impaired skin integrity c. Impaired urinary elimination d. Ineffective breastfeeding - Answer -ANS: b a. There is nothing in the scenario that indicates that this client has had a significant blood loss. b. The client has a 3 laceration. A nursing diagnosis of impaired skin integrity is appropriate. c. The client is voiding well. There is no indication of impaired urinary elimination. d. The client is feeding q 2 h. There is no indication of impaired breastfeeding. True or False - The perinatal nurse teaches the postpartum woman that the most critical time to achieve effectiveness from the application of ice packs to the perineum is during the first 24 hours following birth. - Answer -ANS: True - To reduce perineal swelling and pain that result from bruising, ice packs may be applied every 2 to 4 hours. Patients obtain the most relief when ice packs are applied within the first 24 hours after childbirth. When reviewing potential causes for postpartum hemorrhage with the student nurse, the nurse is sure to include the finding of a(n) __________ bladder. - Answer -
Primary breast engorgement is an increase in the __________ and __________ systems that precedes the initiation of milk production. - Answer -ANS: vascular; lymphatic - Primary breast engorgement is an increase in the vascular and lymphatic systems that precedes the initiation of milk production. Subsequent breast engorgement is related to distention of milk glands. Which of the following nursing actions are important in the care of a postpartum woman who is at risk for orthostatic hypotension? (Select all that apply.) a. Have patient remain in bed for the first 4 hours postbirth. b. Instruct patient to slowly rise to a standing position. c. Open an ammonia ampule and have the patient smell the ammonia prior to getting out of bed. d. Explain to the patient the cause and incidence of orthostatic hypotension. - Answer -ANS: b, d - Postpartum women are at risk for orthostatic hypotension during the first few hours postdelivery. Orthostatic hypotension is a sudden drop in the blood pressure when the woman stands up due to decreased vascular resistance in the pelvis. The woman should be instructed to sit on the edge of her bed for a few minutes and then slowly stand up. The nurse or aide should be with the woman the first few times she ambulates. Ammonia ampules are used when the woman faints and is not given prior to fainting. A woman who gave birth 2 hours ago has a temperature of 37.9C. Select all of the immediate nursing actions.
a. Have patient drink two glasses of fluid over the next hour. b. Explain to the patient that she needs to rest and assist her into a comfortable position. c. Medicate the patient with 500 mg of acetaminophen as per orders. d. Call the patients physician or midwife to report the elevated temperature. - Answer -ANS: a, b - A mild temperature elevation within a few hours of birth can be related to dehydration and exhaustion. Acetaminophen is given if the temperature remains elevated after the woman has been hydrated and rested. The physician or midwife is notified if temperature remains elevated after initial interventions. The perinatal nurse demonstrates the correct technique of postpartum uterine palpation for a student nurse. The nurse explains that support for the lower uterine segment is critical, because without it there is an increased risk of which complication? A. Incorrect measurement B. Intensifying the patients pain C. Uterine edema D. Uterine inversion - Answer -ANS: D - The uterine fundus is palpated by placing one hand on the base of the uterus immediately above the symphysis pubis and the other hand at the level of the umbilicus. The nurse presses inward and downward with the hand positioned on the umbilicus until the fundus is located. The uterus should
legs should be extended and relaxed, with the knees flexed. The examiner grasps the foot and sharply dorsiflexes it. No pain or discomfort should be present. The other leg is assessed in the same manner. If calf pain is elicited, a positive Homans sign is present. The pain occurs from inflammation of the blood vessel and is believed to be associated with the presence of a thrombosis. Pain on dorsiflexion is indicative of DVT in approximately 50% of patients. A negative Homans sign does not rule out DVT. Chadwicks sign is a bluish discoloration of the cervix that may indicate pregnancy. Grey Turners sign is a bruising or bluish discoloration of the flank, often seen in acute pancreatitis. McBurneys sign, an indicator of appendicitis, is a deep tenderness to palpation at McBurneys point. A woman gave birth 12 hours ago. The patient complains of severe abdominal cramping when she breastfeeds her infant. The perinatal nurse should document this condition as which of the following? A. Afterpains B. Bladder hypertonia C. Rectus abdominis diastasis D. Uterine hypertonia - Answer -ANS: A - Afterpains (afterbirth pains) are intermittent uterine contractions that occur during the process of involution. Afterpains are more pronounced in patients with decreased uterine tone due to overdistension, which is associated with multiparity and macrosomia. Breastfeeding and the administration of exogenous oxytocin usually produce pronounced
afterpains because both cause powerful uterine contractions. Patients often describe the sensation as a discomfort similar to menstrual cramps. A postpartum woman is Rho(D)-negative and needs an injection of Rho(D) immune globulin. Which of the following doses would the perinatal nurse expect to be ordered? A. 120 g B. 250 g C. 300 g D. 350 g - Answer -ANS: C - Nonsensitized women who are Rho(D)-negative and have given birth to an Rh(D)- positive infant should receive 300 g of Rho(D) immune globulin (RhoGAM) within 72 hours after giving birth. RhoGAM should be given whether or not the mother received RhoGAM during the antepartum period. In some situations (e.g., hemorrhage, exchange of maternalfetal blood), a larger dose of RhoGAM may be indicated. The perinatal nurse listens as the patient describes her labor and emergency cesarean birth. Providing an opportunity to review this experience may assist the patient in doing which of the following? A. Decreasing her ambivalence about her labor and birth B. Developing more positive feelings about her labor and birth C. Initiating her role development in the letting-go stage
many questions about infant feeding. This is best described as which stage of mothering? A. Taking charge B. Taking hold C. Taking in D. Taking time - Answer -ANS: A - As the mothers physical condition improves, she begins to take charge and enters the taking-hold phase, in which she assumes care for herself and her infant. At this time, the mother eagerly wants information about infant care and shows signs of bonding with her infant. During this phase, the nurse should closely observe motherinfant interactions for signs of poor bonding and, if present, implement actions to facilitate attachment. A postpartum woman who experienced a spontaneous vaginal birth 12 hours ago describes a headache that is worsening. The patient was given two regular-strength acetaminophen (Tylenol) tablets approximately 30 minutes ago but has had no relief from the pain. The most appropriate nursing action at this time is to do which of the following? A. Ask any visitors to leave now or stay quiet. B. Dim the lights in the patients room. C. Notify the patients health-care provider. D. Perform a comprehensive pain assessment. - Answer - ANS: D - The nurse should perform routine, comprehensive pain assessments to include onset, location, intensity, quality, characteristics, and aggravating
and alleviating factors of the discomfort to provide interventions in a timely manner and to enhance effectiveness of medications. The nurse should also ask the patient to rate her pain on a standard 0-to-10 pain scale before and after interventions and to identify her own acceptable comfort level on the scale. The other actions are not warranted at this time. A postpartum woman is complaining of a headache that is worsening despite having taken Tylenol (acetaminophen) an hour ago. She delivered yesterday with epidural anesthesia. What action by the nurse is best? A. Assess if the pain is worse when she sits upright. B. Call the provider and ask for stronger analgesics. C. Document the findings in the patients chart. D. Notify the health-care provider immediately. - Answer - ANS: A - Headache is not uncommon after childbirth. Patients who received epidural or spinal anesthesia may complain of headaches, especially on assuming an upright position. Because this patient had an epidural, the nurse should first assess for this situation. Asking for stronger pain medication should not be done unless the nurse has completed a comprehensive pain assessment. The health- care provider does not need to be notified right away unless the patient has other symptoms, such as blurred vision. Documentation should be thorough, but the nurse needs to take further action first. A new mother is accompanied by her mother during her hospital stay on the postpartum unit. The patients mother
