Maternal Newborn Nursing Test Maternity Nursing: Postpartum 2 — Questions and Answers
Question 1: A postpartum client's fundus is boggy and displaced to the right of midline. What is the priority nursing action?
- Administer oxytocin IV
- Assist client to void or catheterize (Correct answer)
- Massage the fundus firmly
- Notify the physician immediately
Correct answer: Assist client to void or catheterize
A displaced fundus most commonly indicates a full bladder, which must be emptied before fundal massage will be effective.
Question 2: Which finding on a postpartum assessment at 24 hours is considered normal?
- Temperature of 38.8°C (101.8°F)
- Pulse rate of 55 beats/min (Correct answer)
- Blood pressure of 90/50 mmHg
- Respiratory rate of 24 breaths/min
Correct answer: Pulse rate of 55 beats/min
Postpartum bradycardia (50–70 bpm) is a normal physiologic response in the first week after delivery due to increased stroke volume.
Question 3: A nurse is assessing lochia on a postpartum client at day 5. Which characteristic is expected?
- Bright red with clots
- Pink to brown (serosa) (Correct answer)
- Yellow-white (alba)
- Dark red with foul odor
Correct answer: Pink to brown (serosa)
Lochia serosa, which is pinkish-brown and watery, is the normal discharge expected between days 4–10 postpartum.
Question 4: A breastfeeding client asks why her uterine cramping worsens during nursing. What is the correct explanation?
- Infection is causing uterine irritability
- Oxytocin released during suckling causes uterine contractions (Correct answer)
- Progesterone levels drop sharply during breastfeeding
- The uterus is not involuting properly
Correct answer: Oxytocin released during suckling causes uterine contractions
Suckling stimulates oxytocin release from the posterior pituitary, which promotes uterine contractions and involution.
Question 5: A postpartum client has a fourth-degree perineal laceration. Which intervention is most important for comfort and healing?
- Administer stool softeners and encourage adequate fluid intake (Correct answer)
- Limit ambulation for the first 48 hours
- Apply ice packs continuously for 72 hours
- Restrict oral fluid intake to reduce bowel movements
Correct answer: Administer stool softeners and encourage adequate fluid intake
Stool softeners and fluids prevent constipation and straining, which is critical with a fourth-degree laceration that extends into the rectal sphincter.
Question 6: Which statement by a postpartum client indicates she understands teaching about postpartum depression (PPD) risk?
- 'PPD only occurs in women with a history of mental illness.'
- 'I should call my provider if I feel overwhelmed or hopeless after going home.' (Correct answer)
- 'Baby blues and PPD are the same condition.'
- 'PPD symptoms only appear in the first week after delivery.'
Correct answer: 'I should call my provider if I feel overwhelmed or hopeless after going home.'
Clients should be instructed to report persistent sadness, hopelessness, or inability to care for the baby, as PPD can develop up to one year postpartum.
Question 7: A postpartum client is Rh-negative and delivered an Rh-positive infant. When should Rho(D) immune globulin (RhoGAM) be administered?
- Within 12 hours of delivery
- Within 72 hours of delivery (Correct answer)
- At the 6-week postpartum visit
- Only if the Coombs test is positive
Correct answer: Within 72 hours of delivery
RhoGAM must be given within 72 hours of delivery to prevent maternal sensitization against Rh-positive fetal red blood cells.
Maternal Newborn Nursing Test Maternity Nursing: Postpartum 2
A postpartum client's fundus is boggy and displaced to the right of midline.
What is the priority nursing action?