MCN – POSTPARTUM
assist the family in their initial period of
1. A rubella titer result of a 1-day postpartum
client is less than 1:8, and a rubella virus
vaccine is prescribed to be administered
before discharge. The nurse provides
which information to the client about the
vaccine? Select all that apply.
1. Breast-feeding needs to be stopped for
3 months.
2. Pregnancy needs to be avoided for 1 to
3 months.
3. The vaccine is administered by the
subcutaneous route.
4. Exposure to immunosuppressed
individuals needs to be avoided.
5. A hypersensitivity reaction can occur if
the client has an allergy to eggs.
6. The area of the injection needs to be
covered with a sterile gauze for 1 week.
o 2. Pregnancy needs to be avoided for
1 to 3 months.
o 3. The vaccine is administered by the
subcutaneous route.
o 4. Exposure to immunosuppressed
individuals needs to be avoided.
o 5. A hypersensitivity reaction can
occur if the client has an allergy to
eggs.
2. The nurse is providing instructions to a
pregnant client with human
immunodeficiency virus (HIV) infection
regarding care to the newborn after
delivery. The client asks the nurse about
the feeding options that are available.
Which response should the nurse make to
the client?
1. "You will need to bottle-feed your
newborn."
2. "You will need to feed your newborn by
nasogastric tube feeding."
3. "You will be able to breast-feed for 6
months and then will need to switch to
bottle-feeding."
4. "You will be able to breast-feed for 9
months and then will need to switch to
bottle-feeding."
1. "You will need to bottle-feed your newborn."
3. A stillborn baby was delivered in the
birthing suite a few hours ago. After the
delivery, the family remained together,
holding and touching the baby. Which
statement by the nurse would further
grief?
1. "What can I do for you?"
2. "Now you have an angel in heaven."
3. "Don't worry, there is nothing you could
have done to prevent this from
happening."
4. "We will see to it that you have an early
discharge so that you don't have to be
reminded of this experience."
1. "What can I do for you?"
4. The nurse in a maternity unit is providing
emotional support to a client and her
husband who are preparing to be
discharged from the hospital after the birth
of a dead fetus. Which statement made by
the client indicates a component of the
normal grieving process?
1. "We want to attend a support group."
2. "We never want to try to have a baby
again."
3. "We are going to try to adopt a child
immediately."
4. "We are okay, and we are going to try
to have another baby immediately."
1. "We want to attend a support group."
5. The nurse evaluates the ability of a
hepatitis B–positive mother to provide
safe bottle-feeding to her newborn during
postpartum hospitalization. Which
maternal action best exemplifies the
mother's knowledge of potential disease
transmission to the newborn?
1. The mother requests that the window
be closed before feeding.
2. The mother holds the newborn properly
during feeding and burping.
3. The mother tests the temperature of the
formula before initiating feeding.
4. The mother washes and dries her
hands before and after self-care of the
perineum and asks for a pair of gloves
before feeding.
4. The mother washes and dries her hands
before and after self-care of the perineum and
asks for a pair of gloves before feeding.
6. The nurse has provided discharge
instructions to a client who delivered a
healthy newborn by cesarean delivery.
Which statement made by the client
indicates a need for further instruction?
1. "I will begin abdominal exercises
immediately."
2. "I will notify the health care provider if I
develop a fever."
3. "I will turn on my side and push up with
my arms to get out of bed."
4. "I will lift nothing heavier than my
newborn baby for at least 2 weeks."
1. "I will begin abdominal exercises
immediately."
7. After a precipitous delivery, the nurse
notes that the new mother is passive and
only touches her newborn infant briefly
with her fingertips. What should the nurse
do to help the woman process the
delivery?
1. Encourage the mother to breast-feed
soon after birth.
2. Support the mother in her reaction to
the newborn infant.
3. Tell the mother that it is important to
hold the newborn infant.
4. Document a complete account of the
mother's reaction on the birth record.
2. Support the mother in her reaction to the
newborn infant.
8. The nurse in the postpartum unit is caring
for a client who has just delivered a
newborn infant following a pregnancy with
a placenta previa. The nurse reviews the
plan of care and prepares to monitor the
client for which risk associated with
placenta previa?
1. Infection
2. Hemorrhage
3. Chronic hypertension
4. Disseminated intravascular coagulation
2. Hemorrhage
9. The postpartum nurse is taking the vital
signs of a client who delivered a healthy
newborn 4 hours ago. The nurse notes
that the client's temperature is 100.2° F.
What is the priority nursing action?
1. Document the findings.
2. Retake the temperature in 15 minutes.
3. Notify the health care provider (HCP).
4. Increase hydration by encouraging oral
fluids.
4. Increase hydration by encouraging oral
fluids.
10. The nurse is assessing a client who is 6
hours postpartum after delivering a full-
term healthy newborn. The client
complains to the nurse of feelings of
faintness and dizziness. Which nursing
action would be most appropriate?
1. Raise the head of the client's bed.
2. Obtain hemoglobin and hematocrit
levels.
3. Instruct the client to request help when
getting out of bed.
4. Inform the nursery room nurse to avoid
bringing the newborn to the client until the
mother's symptoms have subsided.
3. Instruct the client to request help when
getting out of bed.
11. The postpartum nurse is providing
instructions to a client after delivery of a
healthy newborn. Which time frame
should the nurse relay to the client
regarding the return of bowel function?
1. 3 days postpartum
2. 7 days postpartum
3. On the day of delivery
4. Within 2 weeks postpartum
1. 3 days postpartum
12. The nurse is planning care for a
postpartum client who had a vaginal
delivery 2 hours ago. The client had a
midline episiotomy and has several
hemorrhoids. What is the priority nursing
consideration for this client?
1. Client pain level
2. Inadequate urinary output
3. Client perception of body changes
4. Potential for imbalanced body fluid
volume
1. Client pain level
13. The nurse is providing postpartum
instructions to a client who will be breast-
feeding her newborn. The nurse
determines that the client has understood
the instructions if she makes which
statements? Select all that apply.
1. "I should wear a bra that provides
support."
2. "Drinking alcohol can affect my milk
supply."
3. "The use of caffeine can decrease my
milk supply."
4. "I will start my estrogen birth control
pills again as soon as I get home."
5. "I know if my breasts get engorged I will
limit my breast-feeding and supplement
the baby."
6. "I plan on having bottled water available
in the refrigerator so I can get additional
fluids easily."
o 1. "I should wear a bra that provides
support."
o 2. "Drinking alcohol can affect my milk
supply."
o 3. "The use of caffeine can decrease
my milk supply."
o 6. "I plan on having bottled water
available in the refrigerator so I can
get additional fluids easily."
14. The nurse is teaching a postpartum client
about breast-feeding. Which instruction
should the nurse include?
1. The diet should include additional
fluids.
2. Prenatal vitamins should be
discontinued.
3. Soap should be used to cleanse the
breasts.
4. Birth control measures are unnecessary
while breast-feeding.
1. The diet should include additional fluids.
15. A nurse is preparing to assess the uterine
fundus of a client in the immediate
postpartum period. After locating the
fundus, the nurse notes that the uterus
feels soft and boggy. Which nursing
intervention would be most appropriate?
1. Elevate the client's legs.
2. Massage the fundus until it is firm.
3. Ask the client to turn on her left side.
4. Push on the uterus to assist in
expressing clots.
2. Massage the fundus until it is firm.
16. The nurse is caring for four 1-day
postpartum clients. Which client would
require further nursing action?
1. The client with mild afterpains
2. The client with a pulse rate of 60
beats/minute
3. The client with colostrum discharge
from both breasts
4. The client with lochia that is red and
has a foul-smelling odor
4. The client with lochia that is red and has a
foul-smelling odor
17. When performing a postpartum
assessment on a client, a nurse notes the
presence of clots in the lochia. The nurse
examines the clots and notes that they are
larger than 1 cm. Which nursing action
is most appropriate?
1. Document the findings.
2. Reassess the client in 2 hours.
3. Notify the health care provider.
4. Encourage increased oral intake of
fluids.
3. Notify the health care provider.
18. The nurse is monitoring the amount of
lochia drainage in a client who is 2 hours
postpartum and notes that the client has
saturated a perineal pad in 1 hour. How
should the nurse document this finding?
1. Scant
2. Light
3. Heavy
4. Excessive
3. Heavy
19. The nurse is monitoring a client in the
immediate postpartum period for signs of
hemorrhage. Which sign, if noted, would
be an early sign of excessive blood loss?
1. A temperature of 100.4° F
2. An increase in the pulse rate from 88 to
102 beats/minute
3. A blood pressure change from 130/88
to 124/80 mm Hg
4. An increase in the respiratory rate from
18 to 22 breaths/minute
 2. An increase in the pulse rate from 88 to 102
beats/minute
20. The nurse is preparing a list of self-care
instructions for a postpartum client who
was diagnosed with mastitis. Which
instructions should be included on the
list? Select all that apply.
1. Wear a supportive bra.
2. Rest during the acute phase.
3. Maintain a fluid intake of at least 3000
mL.
4. Continue to breast-feed if the breasts
are not too sore.
5. Take the prescribed antibiotics until the
soreness subsides.
6. Avoid decompression of the breasts by
breast-feeding or breast pump.
o 1. Wear a supportive bra.
o 2. Rest during the acute phase.
o 3. Maintain a fluid intake of at least
3000 mL.
o 4. Continue to breast-feed if the
breasts are not too sore.
21. The nurse is providing instructions about
measures to prevent postpartum mastitis
to a client who is breast-feeding her
newborn. Which client statement would
indicate a need for further instruction?
1. "I should breast-feed every 2 to 3
hours."
2. "I should change the breast pads
frequently."
3. "I should wash my hands well before
breast-feeding."
4. "I should wash my nipples daily with
soap and water."
4. "I should wash my nipples daily with soap
and water."
22. The postpartum nurse is assessing a
client who delivered a healthy infant by
cesarean section for signs and symptoms
of superficial venous thrombosis. Which
sign would the nurse note if superficial
venous thrombosis were present?
1. Paleness of the calf area
2. Coolness of the calf area
3. Enlarged, hardened veins
4. Palpable dorsalis pedis pulses
3. Enlarged, hardened veins
23. A client in a postpartum unit complains of
sudden sharp chest pain and dyspnea.
The nurse notes that the client is
tachycardic and the respiratory rate is
elevated. The nurse suspects a
pulmonary embolism. Which should be
the initial nursing action?
1. Initiate an intravenous line.
2. Assess the client's blood pressure.
3. Prepare to administer morphine sulfate.
4. Administer oxygen, 8 to 10 L/minute, by
face mask.
4. Administer oxygen, 8 to 10 L/minute, by
face mask.
24. The nurse is assessing a client in the
fourth stage of labor and notes that the
fundus is firm, but that bleeding is
excessive. Which should be
the initial nursing action?
1. Record the findings.
2. Massage the fundus.
3. Notify the health care provider (HCP).
4. Place the client in Trendelenburg's
position.
3. Notify the health care provider (HCP).
25. The nurse is preparing to care for four
assigned clients. Which client is at highest
risk for hemorrhage?
1. A primiparous client who delivered 4
hours ago
2. A multiparous client who delivered 6
hours ago
3. A primiparous client who delivered 6
hours ago and had epidural anesthesia
4. A multiparous client who delivered a
large baby after oxytocin (Pitocin)
induction
4. A multiparous client who delivered a large
baby after oxytocin (Pitocin) induction
26. A postpartum client is diagnosed with
cystitis. The nurse should plan for
which priority nursing action in the care
of the client?
1. Providing sitz baths
2. Encouraging fluid intake
3. Placing ice on the perineum
4. Monitoring hemoglobin and hematocrit
levels
 2. Encouraging fluid intake
27. The nurse is monitoring a postpartum
client who received epidural anesthesia
for delivery for the presence of a vulvar
hematoma. Which assessment finding
would best indicate the presence of a
hematoma?
1. Changes in vital signs
2. Signs of heavy bruising
3. Complaints of intense pain
4. Complaints of a tearing sensation
1. Changes in vital signs
28. The nurse is developing a plan of care for
a postpartum client with a small vulvar
hematoma. The nurse should include
which specific action during the first 12
hours after delivery?
1. Assess vital signs every 4 hours.
2. Measure fundal height every 4 hours.
3. Prepare an ice pack for application to
the area.
4. Inform the health care provider of
assessment findings.
3. Prepare an ice pack for application to the
area.
29. On assessment of a postpartum client, the
nurse notes that the uterus feels soft and
boggy. The nurse should take
which initial action?
1. Elevate the client's legs.
2. Document the findings.
3. Massage the fundus until it is firm.
4. Push on the uterus to assist in
expressing clots.
3. Massage the fundus until it is firm.
30. On the second postpartum day, a client
complains of burning on urination,
urgency, and frequency of urination. A
urinalysis indicates the presence of a
urinary tract infection. The nurse instructs
the client regarding measures to take for
the treatment of the infection. Which client
statement indicates to the nurse the need
for further instruction?
1. "I need to urinate frequently throughout
the day."
2. "The prescribed medication must be
taken until it is finished."
3. "My fluid intake should be increased to
at least 3000 mL daily."
4. "Foods and fluids that will increase
urine alkalinity should be consumed."
4. "Foods and fluids that will increase urine
alkalinity should be consumed."
31. The nurse is assessing a client for signs
of postpartum depression. Which
observation, if noted in the new mother,
would indicate the need for further
assessment related to this form of
depression?
1. The mother is caring for the infant in a
loving manner.
2. The mother demonstrates an interest in
the surroundings.
3. The mother constantly complains of
tiredness and fatigue.
4. The mother looks forward to visits from
the father of the newborn.
3. The mother constantly complains of
tiredness and fatigue.
32. A postpartum client is attempting to
breast-feed for the first time. The nurse
notes that the client has inverted nipples.
What nursing action should the nurse take
to assist the client in breast-feeding the
newborn infant?
1. Massage the breasts, applying gentle
pressure on the areolas with the thumb
and forefinger.
2. Have the mother grasp her areola
between the thumb and forefinger and tug
firmly to get the nipple to protrude.
3. Encourage taking a cool shower,
allowing the water to run over the breasts,
because this will encourage the nipples to
protrude.
4. Provide breast shells and assist the
mother with using a breast pump before
each feeding to make the nipples easier
for the newborn infant to grasp.
4. Provide breast shells and assist the mother
with using a breast pump before each feeding
to make the nipples easier for the newborn
infant to grasp.
33. 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?
1. "Mastitis usually involves both breasts."
2. "Mastitis can occur at any time during
breast-feeding."
3. "Mastitis usually is caused by wearing a
supportive bra."
4. "Mastitis is most common for women
who have breast-fed in the past."
2. "Mastitis can occur at any time during
breast-feeding."
34. The nurse is developing a plan of care for
a client recovering from a cesarean
delivery. Which action should the nurse
encourage the client to do to prevent
thrombophlebitis?
1. Elevate her legs.
2. Remain on bed rest.
3. Ambulate frequently.
4. Apply warm, moist packs to the legs.
3. Ambulate frequently.
35. The nurse performs an assessment on a
client who is 4 hours postpartum. The
nurse notes that the client has cool,
clammy skin and is restless and
excessively thirsty.
What immediate action should the nurse
take?
1. Provide oral fluids and begin fundal
massage.
2. Begin hourly pad counts and reassure
the client.
3. Elevate the head of the bed and assess
vital signs.
4. Assess for hypovolemia and notify the
health care provider (HCP).
4. Assess for hypovolemia and notify the
health care provider (HCP).
36. The nurse is monitoring a postpartum
client in the fourth stage of labor. Which
finding, if noted by the nurse, would
indicate a complication related to a
laceration of the birth canal?
1. Presence of dark red lochia
2. Palpation of the uterus as a firm
contracted ball
3. The saturation of more than one
peripad per hour
4. Palpation of the fundus at the level of
the umbilicus
3. The saturation of more than one peripad
per hour
37. The nurse is providing instructions to a
client who has been diagnosed with
mastitis. Which statement, if made by the
client, indicates a need for further
instructions?
1. "I need to wear a supportive bra to
relieve the discomfort."
2. "I need to stop breast-feeding until this
condition resolves."
3. "I can use analgesics to assist in
alleviating some of the discomfort."
4. "I need to take antibiotics, and I should
begin to feel better in 24 to 48 hours."
2. "I need to stop breast-feeding until this
condition resolves."
38. A postpartum client with deep vein
thrombosis is being treated with
anticoagulant therapy. The nurse
understands that the client's response to
treatment will be evaluated by regularly
assessing the client for which symptoms?
1. Dysuria, ecchymosis, and vertigo
2. Epistaxis, hematuria, and dysuria
3. Hematuria, ecchymosis, and vertigo
4. Hematuria, ecchymosis, and epistaxis
4. Hematuria, ecchymosis, and epistaxis
39. After surgical evacuation and repair of a
paravaginal hematoma, a client is
discharged 3 days postpartum. The nurse
determines that the client needs further
discharge instructions when the client
makes which statement?
1. "I will probably need my mother to help
me with housekeeping."
 2. "Because I am so sore, I will nurse the
baby while lying on my side."
3. "My husband and I will not have
intercourse until the stitches are healed."
4. "The only medications I will take are
prenatal vitamins and stool softeners."
4. "The only medications I will take are
prenatal vitamins and stool softeners."
40. The nurse is developing a plan of care for
a postpartum client who was diagnosed
with superficial venous thrombosis. The
nurse anticipates that which intervention
will be prescribed?
1. Administration of anticoagulants
2. Elevation of the affected extremity
3. Ambulation eight to ten times daily
4. Application of ice packs to the affected
area
2. Elevation of the affected extremity
41. A new mother received epidural
anesthesia during labor and had a forceps
delivery after pushing for 2 hours. At 6
hours postpartum her systolic blood
pressure has dropped 20 points, her
diastolic blood pressure has dropped 10
points, and her pulse is 120 beats/min.
The client is anxious and restless. On
further assessment, a vulvar hematoma is
verified. After notifying the health care
provider, what is the nurse's next action?
1. Reassure the client.
2. Monitor fundal height.
3. Apply perineal pressure.
4. Prepare the client for surgery.
4. Prepare the client for surgery.
42. The home care nurse visits a client who
has delivered a healthy newborn infant via
vaginal delivery. An episiotomy was
performed, and the woman has developed
a wound infection at the episiotomy site.
The nurse provides instructions to the
client regarding care related to the
infection. Which statement, if made by the
mother, indicates a need for further
instructions?
1. "I need to take the antibiotics as
prescribed."
2. "I need to take warm sitz baths to
promote healing."
3. "I need to apply warm compresses to
provide comfort."
4. "I need to isolate the infant for 48 hours
after beginning the antibiotics."
4. "I need to isolate the infant for 48 hours
after beginning the antibiotics."
43. A client has just had surgery to deliver a
nonviable fetus resulting from abruptio
placentae. As a result of the abruptio
placentae, the client develops
disseminated intravascular coagulation
(DIC) and is told about the complication.
The client begins to cry and screams,
"God, just let me die now!" Which client
problem should be the priority for the
client at this time?
1. Lack of power about the situation
2. Grieving because of the loss of the
baby
3. Lack of knowledge regarding what
occurred
4. Concern about the loss of the baby and
personal health
4. Concern about the loss of the baby and
personal health
44. The rubella vaccine has been prescribed
for a new mother. Which statement should
the postpartum nurse make when
providing information about the vaccine to
the client?
1. "You should avoid sexual intercourse
for 2 weeks after administration of the
vaccine."
2. "You should not become pregnant for 2
to 3 months after administration of the
vaccine."
3. "You should avoid heat and extreme
temperature changes for 1 week after
administration of the vaccine."
4. "You must sign an informed consent
because anaphylactic reactions can occur
with the administration of this vaccine."
2. "You should not become pregnant for 2 to 3
months after administration of the vaccine."
45. The nursing student is assigned to care
for a client in the postpartum unit. The
coassigned nurse asks the student to
 identify the most objective method to
assess the amount of lochial flow in the
client. Which statement, if made by the
student, indicates an understanding of this
method?
1. "I can estimate the amount of blood
loss by gauging the amount of staining on
a perineal pad."
2. "I should ask the client to keep a record
and document every time the perineal pad
is changed."
3. "I should weigh the perineal pad before
and after use and note the amount of time
between each pad change."
4. "I can look at the perineal pad and
gauge the amount of staining and relate it
to the amount of time between pad
changes."
3. "I should weigh the perineal pad before and
after use and note the amount of time
between each pad change."
46. The nurse in the postpartum unit is
observing the mother-infant bonding
process in a client. Which observation, if
made by the nurse, indicates the potential
for a maladaptive interaction?
1. The mother is observed talking to the
newborn.
2. The mother performs cord care for the
newborn.
3. The mother verbalizes discomfort with
the new role of motherhood.
4. The mother requests that the nurse
feed the newborn because she is feeling
fatigued.
4. The mother requests that the nurse feed
the newborn because she is feeling fatigued.
47. The postpartum nurse is caring for a
woman who just delivered a healthy
newborn. The nurse should
be most concerned with the presence of
subinvolution if which occurs?
1. The presence of afterpains
2. Retained placental fragments from
delivery
3. An oral temperature of 99.0° F following
delivery
4. Increased estrogen and progesterone
levels as noted on laboratory analysis
2. Retained placental fragments from delivery
48. The nurse is monitoring a postpartum
client who is at risk of developing
postpartum endometritis. Which finding, if
noted during the first 24 hours after
delivery, would support a diagnosis of
postpartum endometritis?
1. Abdominal tenderness and chills
2. Increased perspiration and appetite
3. Maternal oral temperature of 100.2° F
4. Uterus two fingerbreadths below
midline and firm
1. Abdominal tenderness and chills
49. Which nursing intervention would be most
appropriate for a postpartum client with a
diagnosis of endometritis to facilitate
participation in newborn care?
1. Limit fluid intake.
2. Maintain the client in a supine position.
3. Ask family members to care for the
newborn.
4. Encourage the client to take pain
medication as prescribed.
4. Encourage the client to take pain
medication as prescribed.
50. The nurse is caring for a client in the
postpartum period immediately after
delivery. The nurse performs an
assessment on the client and prepares to
assess uterine involution by taking which
action?
1. Monitoring the vital signs
2. Palpating the uterine fundus
3. Auscultating the bowel sounds
4. Assessing the amount of drainage on
the peripad
2. Palpating the uterine fundus
51. The nurse is assessing a client in the
postpartum period and suspects the
presence of uterine atony. Which is
the initial nursing action?
1. Massage the uterus until firm.
2. Take the client's blood pressure.
3. Contact the health care provider (HCP).
4. Assess the amount of drainage on the
peripad.
 1. Massage the uterus until firm.
52. The postpartum unit nurse is developing a
plan of care for a first-time mother and
identifies the need for measures that will
promote parent-infant bonding. Which
measure should the nurse include in the
plan?
1. Use a low-pitched voice to speak to the
infant.
2. Encourage the mother to hold the infant
when the infant cries.
3. Encourage the parents to allow the
infant to sleep in the parental bed.
4. Encourage the mother to allow the
nursing staff to care for the infant during
her hospital stay until she is discharged.
2. Encourage the mother to hold the infant
when the infant cries.
53. The postpartum unit nurse has provided
discharge instructions to a client planning
to breast-feed her normal, healthy infant.
Which statement by the client indicates an
understanding of the instructions?
1. "If I experience any sweating during the
night, I should call the health care
provider."
2. "If I have uterine cramping while breast-
feeding, I should contact the health care
provider."
3. "If I'm still having bloody vaginal
drainage in a week, I should contact the
health care provider."
4. "If I notice any pain, redness, or
swelling in my breasts, I should contact
the health care provider."
4. "If I notice any pain, redness, or swelling in
my breasts, I should contact the health care
provider."
54. A client arrives at the postpartum unit after
delivery of her infant. On performing an
assessment, the nurse notes that the
client is shaking uncontrollably. Which
nursing action would be appropriate?
1. Massage the fundus.
2. Contact the health care provider.
3. Cover the client with a warm blanket.
4. Place the client in Trendelenburg's
position.
3. Cover the client with a warm blanket.
55. The postpartum unit nurse has provided
information regarding performing a sitz
bath to a new mother after a vaginal
delivery. The client demonstrates
understanding of the purpose of the sitz
bath by stating that the sitz bath will
promote which action?
1. Numb the tissue.
2. Stimulate a bowel movement.
3. Reduce the edema and swelling.
4. Assist in healing and provide comfort.
4. Assist in healing and provide comfort.
56. A nurse is assessing the fundus in a
postpartum woman and notes that the
uterus is soft and spongy and is not firmly
contracted. The nurse should prepare to
implement which interventions? Select all
that apply.
1. Massaging the uterus
2. Pushing gently on the uterus
3. Assisting the woman to urinate
4. Rechecking the uterus in 1 hour
5. Checking for a distended bladder
6. Calling the delivery room to schedule
an abdominal hysterectomy
o 1. Massaging the uterus
o 3. Assisting the woman to urinate
o 5. Checking for a distended bladder
57. A woman infected with the human
immunodeficiency virus (HIV) has given
birth to a normal-appearing infant, and the
nurse provides instructions about newborn
infant care. Which statement by the
mother indicates a need for further
instruction?
1. "I'm going to breast-feed my baby
starting right away."
2. "I need to wash my hands before and
after bathroom use."
3. "My baby needs to be on antiviral
medications for the next 6 weeks."
4. "I am going to contact some support
groups listed in my take-home material to
help me with everything I'll have to deal
with when I get home."
1. "I'm going to breast-feed my baby starting
right away."
58. The clinic nurse is performing an
assessment on a client who is 6 days
postpartum. When assessing involution,
the nurse expects the uterine fundus to be
located at which area?
1. A
2. B
3. C
4. D
4. D
59. A client with known cardiac disease has
been admitted to the postpartum care unit
after an uneventful delivery. The unit
nurse instructs the client to use the call
button for assistance whenever she needs
to get out of bed or wishes to care for her
infant. Which postpartum complication is
the nurse most concerned about for this
client?
1. Postpartum infection
2. Maternal attachment
3. Maternal overexertion
4. Postpartum newborn-mother bonding
3. Maternal overexertion
60. A postpartum care unit nurse is reviewing
the records of 4 new mothers admitted to
the unit. The nurse determines that which
mother would be least likely at risk for
developing a puerperal infection?
1. A mother who had ten vaginal exams
during labor
2. A mother with a history of previous
puerperal infections
3. A mother who gave birth vaginally to a
3200 gram infant
4. A mother who experienced prolonged
rupture of the membranes
3. A mother who gave birth vaginally to a 3200
gram infant
61. A postpartum unit nurse is preparing to
care for a client who has just delivered a
healthy newborn. In the immediate
postpartum period what is the
recommended frequency for the nurse to
assess the client's vital signs?
1. Every hour for the first 2 hours and then
every 4 hours
2. Every 30 minutes during the first hour
and then every hour for the next 2 hours
3. Every 5 minutes for the first 30 minutes
and then every hour for the next 4 hours
4. Every 15 minutes during the first hour
and then every 30 minutes for the next 2
hours
4. Every 15 minutes during the first hour and
then every 30 minutes for the next 2 hours
62. The postpartum unit nurse is performing
an assessment on a client who is at risk
for thrombophlebitis. Which nursing action
is indicated in assessing for
thrombophlebitis?
1. Palpate for pedal pulses.
2. Ask the client about pain in the calf
area.
3. Assess for the presence of vaginal
hematoma.
4. Ask the client to ambulate and assess
for the presence of pain.
2. Ask the client about pain in the calf area.
63. The rubella vaccine is prescribed to be
administered to a client 2 days after
delivery of her child. The nurse preparing
to administer the vaccine develops a list of
the potential risks associated with this
vaccine. The nurse reviews the list with
the client and cautions the client to avoid
which situation?
1. Sunlight for 3 days
2. Scratching the injection site
3. Pregnancy for 2 to 3 months after the
vaccination
4. Sexual intercourse for 2 to 3 months
after the vaccination
3. Pregnancy for 2 to 3 months after the
vaccination
64. On the second postpartum day, a woman
complains of burning on urination,
urgency, and frequency of urination. A
urinalysis is done, and the results indicate
the presence of a urinary tract infection.
The nurse instructs the new mother
regarding measures to take for treatment
of the infection. Which statement, if made
by the mother, would indicate a need for
further instructions?
1. "I need to urinate frequently throughout
the day."
2. "The prescribed medication must be
taken until it is finished."
3. "My fluid intake should be increased to
at least 3000 mL daily."
4. "Foods and fluids that will increase
urine alkalinity should be consumed."
4. "Foods and fluids that will increase urine
alkalinity should be consumed."
65. A pregnant woman who is infected with
the human immunodeficiency virus (HIV)
delivers a newborn infant, and the nurse
provides instructions to help the mother
regarding care of the infant. Which
statement by the client would indicate
the need for further instructions?
1. "I will be sure to wash my hands before
and after bathroom use."
2. "I need to breast-feed, especially for the
first 6 weeks postpartum."
3. "Support groups are available to assist
me with understanding my diagnosis of
HIV."
4. "My newborn infant should be on
antiviral medications for the first 6 weeks
after delivery."
2. "I need to breast-feed, especially for the
first 6 weeks postpartum."
66. The home care nurse's assignment is to
visit a new mother at home 24 to 48 hours
after discharge. What should the nurse
expect to note in a healthy mother who is
breast-feeding her newborn infant?
1. The mother has cracked nipples and
feeds the infant with a supplemental
bottle.
2. The mother complains of breast
engorgement, and the infant
demonstrates difficulty in latching onto the
breast.
3. The mother is breast-feeding the infant
with the infant's head turned toward her
breast and the body flat in her arms; the
mother has sore nipples, and the infant
has a suck blister.
4. The mother is breast-feeding with the
infant in a tummy-to-tummy position
without signs of cracked nipples; the baby
demonstrates bursts of sucking, followed
by a pause and swallow.
4. The mother is breast-feeding with the infant
in a tummy-to-tummy position without signs of
cracked nipples; the baby demonstrates
bursts of sucking, followed by a pause and
swallow.
67. The nurse who is employed in a prenatal
clinic is performing prenatal assessments
on clients who are in their first trimester of
pregnancy. The nurse is concerned with
identifying clients who may be at risk for
the development of postpartum
complications. Which client would be at
the lowest risk for development of
postpartum thromboembolic disorders?
1. A 39-year-old woman who reports that
she smokes
2. A 26-year-old woman with a family
history of thrombophlebitis
3. A 37-year-old woman in her fourth
pregnancy who is overweight
4. A 22-year-old woman with a first
pregnancy who states that oral
contraceptives taken in the past have
caused thrombophlebitis
2. A 26-year-old woman with a family history
of thrombophlebitis
68. The nurse has provided instructions for a
postpartum client at risk for thrombosis
regarding measures to prevent its
occurrence. Which statement, if made by
the client, indicates a need for further
education?
1. "I should apply my antiembolism
stockings after breakfast."
2. "I should avoid prolonged standing or
sitting in one position."
3. "I should perform regularly scheduled
exercise such as walking."
4. "I should avoid using pillows under my
 knees to prevent pressure in the back of
my knee area."
1. "I should apply my antiembolism stockings
after breakfast."
69. The discharge nurse is discussing mastitis
with a postpartum client. Which statement
made by the client indicates a need for
further instruction?
1. "If I develop a hot, reddened, triangle-
shaped area on my breast, I should
contact my health care provider."
2. "Antibiotics, rest, warm compresses,
and adequate fluid intake are all important
for the treatment of mastitis."
3. "If I develop a fever, chills, or body
aches at any time after discharge, I should
stop breast-feeding immediately."
4. "I may develop mastitis if I wear
underwire bras, experience excessive
fatigue, or suddenly decrease the number
of feedings."
3. "If I develop a fever, chills, or body aches at
any time after discharge, I should stop breast-
feeding immediately."
70. On assessment of a client who is 30
minutes into the fourth stage of labor, the
nurse finds the client's perineal pad
saturated in blood and blood soaked into
the bed linen under the client's buttocks.
Which is the nurse's initial action?
1. Call the health care provider.
2. Assess the client's vital signs.
3. Gently message the uterine fundus.
4. Administer a 300-mL bolus of a 20
units/L oxytocin (Pitocin) solution.
3. Gently message the uterine fundus.
71. After receiving report at the beginning of
the 0700 shift, the nurse must decide in
what order the clients should be
assessed. How would the nurse plan
assessments? Arrange the clients in the
order that they should be assessed. All
options must be used.
1. An 8-hour post–vaginal delivery gravida
2, para 2 client who is scheduled for a
bilateral tubal ligation at 1200 today and
has a continuous peripheral intravenous
(IV) solution of 5% dextrose in lactated
Ringer's solution (D5LR) with 20 milliunits
of oxytocin (Pitocin) infusing at 125 mL/hr.
2. A 12-hour post–cesarean section
delivery of a gravida 3, para 3, who
reports a return of feeling in her lower
extremities as well as a sensation of
wetness underneath her buttocks.
3. A 48-hour post–cesarean section
delivery of a gravida 1, para 1, who
reports not yet having a bowel movement
since delivery and requests a stool
softener.
4. A 24-hour post–vaginal delivery of a
gravida 4, para 4, who is complaining of
abdominal cramping after nursing her
baby and requesting ibuprofen (Motrin).
o 2. A 12-hour post–cesarean section
delivery of a gravida 3, para 3, who
reports a return of feeling in her lower
extremities as well as a sensation of
wetness underneath her buttocks.
o 4. A 24-hour post–vaginal delivery of a
gravida 4, para 4, who is complaining
of abdominal cramping after nursing
her baby and requesting ibuprofen
(Motrin).
o 1. 1. An 8-hour post–vaginal delivery
gravida 2, para 2 client who is
scheduled for a bilateral tubal ligation
at 1200 today and has a continuous
peripheral intravenous (IV) solution of
5% dextrose in lactated Ringer's
solution (D5LR) with 20 milliunits of
oxytocin (Pitocin) infusing at 125
mL/hr.
o 3. 3. A 48-hour post–cesarean section
delivery of a gravida 1, para 1, who
reports not yet having a bowel
movement since delivery and requests
a stool softener.
72. A client who is a gravida III, para III had a
cesarean section 1 day ago. She is being
treated prophylactically for endometritis.
She is complaining of abdominal cramping
at a level of 6 on pain level scale of 1 to
10 (with 10 being the greatest amount of
pain) and fears having her first bowel
movement. These medications are
prescribed and due now. Based
on priority, in which order should the
nurse administer the
medications? Arrange the medications
in the order that they should be
administered. All options must be
used.
1. Prenatal vitamin 1 tablet orally daily
 2. Docusate sodium (Colace) 100 mg
orally
3. Ketorolac (Toradol) 30 mg by
intravenous push over 3 minutes
4. Ampicillin sodium (Ampicillin) 1 g
intravenous (IV) piggyback over 60
minutes
o 3. Ketorolac (Toradol) 30 mg by
intravenous push over 3 minutes
o 4. Ampicillin sodium (Ampicillin) 1 g
intravenous (IV) piggyback over 60
minutes
o 2. Docusate sodium (Colace) 100 mg
orally
o 1. Prenatal vitamin 1 tablet orally daily
76. A nurse has just received an intershift
73. A nurse is checking lochia discharge in a
woman in the immediate postpartum
period. The nurse notes that the lochia is
bright red and contains some small clots.
Based on this data, the nurse should
make which interpretation?
1. The client is hemorrhaging.
2. The client needs to increase oral fluids.
3. The client is experiencing normal lochia
discharge.
4. The client's health care provider needs
to be notified of the finding.
3. The client is experiencing normal lochia
discharge.
2. "You should avoid sexual intercourse
for 2 weeks after the administration of the
vaccine."
3. "You should not become pregnant for 1
to 3 months after the administration of the
vaccine."
4. "You should avoid heat and extreme
temperature changes for a week after the
administration of the vaccine."
3. "You should not become pregnant for 1 to 3
months after the administration of the
vaccine."
report. After reviewing the client
assignment and the appropriate medical
records, the nurse determines that which
client is most at risk for developing
postdelivery endometritis?
1. A primigravida with a normal
spontaneous vaginal delivery
2. A gravida II who delivered vaginally
following an 18-hour labor
3. A client experiencing an elective
cesarean delivery at 38 weeks' gestation
4. An adolescent experiencing an
emergency cesarean delivery for fetal
distress

4. An adolescent experiencing an emergency

74. A postpartum woman with mastitis in the
cesarean delivery for fetal distress
right breast complains that the breast is
too sore for her to breast-feed her infant.
77. A nurse provides a list of discharge
The nurse should tell the client to
instructions to a client who has delivered a
implement which measure?
healthy newborn by cesarean delivery.
1. Pump both breasts and discard the
Which statement by the client indicates
milk.
the need for further teaching?
2. Bottle-feed the infant on a temporary
1. "I can begin abdominal exercises
basis.
immediately."
3. Breast-feed from the left breast and
2. "I need to notify the health care
gently pump the right breast.
provider if I develop a fever."
4. Stop breast-feeding from both breasts
3. "I can't lift anything heavier than my
until this condition resolves.
newborn for at least 2 weeks."
3. Breast-feed from the left breast and gently
4. "I need to turn on my side and push up
pump the right breast. with my arms to get out of bed."

1. "I can begin abdominal exercises

75. The rubella vaccine has been prescribed
immediately."
for a new mother. Which statement should
the postpartum nurse make when
78. A nurse is caring for a client who has just
providing information about the vaccine to
delivered a newborn following a
the client?
pregnancy with a placenta previa. When
1. "You will need a second vaccination at
reviewing the plan of care, the nurse
your 6-week postpartum visit."
 should prepare to monitor the client for
which risk that is associated with placenta
previa?
1. Infection
2. Hemorrhage
3. Chronic hypertension
4. Disseminated intravascular coagulation
2. Hemorrhage
79. The nurse is preparing to perform a fundal
assessment on a postpartum client. The
nurse understands that which is
the initial nursing action when performing
this assessment?
1. Ask the client to turn on her side.
2. Ask the client to urinate and empty her
bladder.
3. Massage the fundus gently before
determining the level of the fundus.
4. Ask the client to lie flat on her back,
with her knees and legs flat and straight.
2. Ask the client to urinate and empty her
bladder.
80. The nurse is preparing to care for a client
in the immediate postpartum period who
has just delivered a healthy newborn. How
often should the nurse plan to take the
client's vital signs?
1. Hourly for the first 2 hours and then
every 4 hours
2. 30 minutes during the first hour and
then every hour for the next 2 hours
3. 5 minutes for the first 30 minutes and
then every hour for the next 4 hours
4. 15 minutes during the first hour and
then every 30 minutes for the next 2 hours
4. 15 minutes during the first hour and then
every 30 minutes for the next 2 hours
81. The nurse is providing nutritional
counseling to a new mother who is breast-
feeding her newborn. The nurse should
instruct the client that her calorie needs
should increase by approximately how
many calories a day?
1. 100
2. 300
3. 500
4. 1000
3. 500
82. The postpartum client asks the nurse
about the occurrence of afterpains. The
nurse informs the client that afterpains will
be especially noticeable during which
activity?
1. Ambulating
2. Breast-feeding
3. Taking sitz baths
4. Arriving home and activities are
increased
2. Breast-feeding
83. The nursing instructor is reviewing the
plan of care with a student regarding care
of a postpartum client. The instructor asks
the nursing student about the taking-in
phase according to Rubin's phases of
regeneration and the client behaviors that
are most likely to occur during this
phase. Which response made by the
student indicates an understanding of this
phase?
1. "The client would be independent."
2. "The client initiates activities on her
own."
3. "The client participates in mothering
tasks."
4. "The client is self-focused and talks to
others about labor."
4. "The client is self-focused and talks to
others about labor."
84. The nurse is teaching a new mother how
to care for her newborn. The nurse notes
that the client is very fearful and reluctant
to handle the newborn and notes that this
is the client's first child. Which nursing
intervention is least appropriate in
assisting the promotion of mother-infant
interaction and bonding?
1. Accepting the client's feelings
2. Acknowledging the client's
apprehension
3. Assisting the client with giving the baths
to allow her to become more at ease
4. Leaving the infant with the client so that
she will be required to provide the care
4. Leaving the infant with the client so that she
will be required to provide the care
85. The nurse is assigned to care for a client
who has chosen to formula-feed her
infant. The nurse should plan to provide
which instruction to the client?
1. Apply a heating pad to breasts for
comfort.
2. Wear a breast shield to correct nipple
inversion.
3. Wear a supportive brassiere
continuously for 72 hours.
4. Use the manual breast pump provided
to express milk.
3. Wear a supportive brassiere continuously
for 72 hours.
86. The postpartum client who had a vaginal
delivery of a healthy newborn has a
prescription for a sitz bath. The nurse
should tell the client that the sitz bath will
provide which effect?
1. Numb the tissue.
2. Stimulate a bowel movement.
3. Reduce the edema and swelling.
4. Promote healing and provide comfort.
4. Promote healing and provide comfort.
87. A nurse is monitoring a new mother in the
fourth stage of labor for signs of
hemorrhage. Which indicates
an early sign of excessive blood loss?
1. A temperature of 100.4º F
2. An increased pulse rate of 88 to 102
beats/min
3. A blood pressure change from 130/88
to 124/80 mm Hg
4. An increase in the respiratory rate from
18 to 22 breaths/min
2. An increased pulse rate of 88 to 102
beats/min
88. A nurse is providing instructions to a client
who has been diagnosed with mastitis.
Which statement made by the client
indicates a need for further teaching?
1. "I need to wear a supportive bra to
relieve the discomfort."
2. "I need to stop breast-feeding until this
condition resolves."
3. "I can use analgesics to assist in
alleviating some of the discomfort."
4. "I need to take antibiotics, and I should
begin to feel better in 24 to 48 hours."
2. "I need to stop breast-feeding until this
condition resolves."
89. A nurse is monitoring the client for signs
of postpartum depression. Which would
indicate the need for further assessment
related to this form of depression?
1. The client is caring for the infant in a
loving manner.
2. The client demonstrates an interest in
the surroundings.
3. The client constantly complains of
tiredness and fatigue.
4. The client looks forward to visits from
the father of the newborn.
3. The client constantly complains of tiredness
and fatigue.
90. The nurse caring for a client with a
diagnosis of subinvolution should
understand that which is a primary cause
of this diagnosis?
1. Afterpains
2. Increased estrogen levels
3. Increased progesterone levels
4. Retained placental fragments from
delivery
4. Retained placental fragments from delivery
91. The nurse has determined that a
postpartum client has physical findings
consistent with uterine atony. The nurse
should plan to take which action first?
1. Massage the uterus until firm.
2. Take the client's blood pressure.
3. Ask the client about the presence of
pain.
4. Recheck the amount of drainage on the
peripad.
1. Massage the uterus until firm.
92. When planning care for a postpartum
client that plans to breast-feed her infant,
which important piece of information
should the nurse include in the teaching
plan to prevent the development of
mastitis?
1. Offer only one breast at each feeding.
 2. Massage distended areas as the infant
nurses.
3. Cleanse nipples with a mild
antibacterial soap before and after infant
feedings.
4. Express and discard milk from the
affected breast at the first signs of
mastitis.
2. Massage distended areas as the infant
nurses.
93. Which instructions should a nurse provide
to a client following delivery regarding
care of the episiotomy site to prevent
infection? Select all that apply.
1. Report a foul-smelling discharge.
2. Take a warm sitz baths three times a
day.
3. Change the perineum pads three times
a day.
4. Use warm water to rinse the perineum
after elimination.
5. Wipe the perineum from front to back
after voiding and defecation.
o 1. Report a foul-smelling discharge.
o 2. Take a warm sitz baths three times
a day.
o 4. Use warm water to rinse the
perineum after elimination.
o 5. Wipe the perineum from front to
back after voiding and defecation.
94. A nurse visits a client at home who
delivered a healthy newborn 2 days ago.
The client is complaining of breast
discomfort. The nurse notes that the client
is experiencing breast engorgement.
Which instructions should the nurse
provide to the client regarding relief of the
engorgement? Select all that apply.
1. Wear a supportive bra between
feedings.
2. Avoid breast-feeding during the time of
breast engorgement.
3. Feed the infant at least every 2 hours
for 15 to 20 minutes on each side.
4. Apply moist heat to both breasts for
about 20 minutes before a feeding.
5. Massage the breasts gently during a
feeding, from the outer areas to the
nipples.
o 1. Wear a supportive bra between
feedings.
o 3. Feed the infant at least every 2
hours for 15 to 20 minutes on each
side.
o 4. Apply moist heat to both breasts for
about 20 minutes before a feeding.
o 5. Massage the breasts gently during
a feeding, from the outer areas to the
nipples.
95. On the second postpartum day, a client
complains of burning, urgency, and
frequency of urination. A urinalysis is
obtained, and the results indicate the
presence of a urinary tract infection.
Which measures should the nurse instruct
the client to take regarding the prevention
and treatment of the infection? Select all
that apply.
1. Urinate frequently throughout the day.
2. Wipe the perineal area from front to
back after urinating.
3. Fluid intake should be increased to at
least 3000 mL/day.
4. Prescribed medication must be taken
until it is completed.
5. Foods and fluids that will increase urine
alkalinity should be consumed.
o 1. Urinate frequently throughout the
day.
o 2. Wipe the perineal area from front to
back after urinating.
o 3. Fluid intake should be increased to
at least 3000 mL/day.
o 4. Prescribed medication must be
taken until it is completed.