Maternal Newborn Nursing Test Maternity Nursing: Postpartum 3 — Questions and Answers
Question 1: A postpartum client develops a temperature of 38.5°C (101.3°F) on day 3. Which source of infection should the nurse assess first?
- Urinary tract
- Endometrium (Correct answer)
- Breast tissue
- Perineal wound
Correct answer: Endometrium
Endometritis is the most common cause of postpartum fever after the first 24 hours and is characterized by uterine tenderness and foul-smelling lochia.
Question 2: A nurse notes that a postpartum client's lochia has returned to bright red after being pink. What is the most likely cause?
- Normal progression of involution
- Excessive activity or resuming intercourse too soon (Correct answer)
- Retained placental fragments
- Development of a vaginal hematoma
Correct answer: Excessive activity or resuming intercourse too soon
A return to bright red lochia (lochia rubra) after it has lightened usually indicates the client has been too physically active.
Question 3: Which assessment finding indicates successful postpartum adaptation of the urinary system?
- Urine output less than 200 mL in 8 hours
- Voiding at least 150 mL with first void after delivery (Correct answer)
- Urinary retention requiring catheterization at 4 hours postpartum
- Concentrated urine with specific gravity above 1.030
Correct answer: Voiding at least 150 mL with first void after delivery
The client should void spontaneously within 6–8 hours postpartum; a void of at least 150 mL suggests adequate bladder function.
Question 4: A postpartum client is being discharged on postpartum day 2. Which instruction about activity is most appropriate?
- Avoid all physical activity for six weeks
- Begin gentle walking and gradually increase activity as tolerated (Correct answer)
- Return to full pre-pregnancy exercise immediately
- Limit stair climbing for at least four weeks
Correct answer: Begin gentle walking and gradually increase activity as tolerated
Gradual resumption of activity starting with gentle walking promotes recovery without risking excessive bleeding or fatigue.
Question 5: A client who delivered 48 hours ago reports painful, hard, warm breast engorgement. She is formula-feeding. What intervention should the nurse recommend?
- Apply warm compresses and manually express milk
- Wear a supportive bra, apply ice packs, and avoid nipple stimulation (Correct answer)
- Initiate breastfeeding to relieve pressure
- Administer a diuretic as ordered
Correct answer: Wear a supportive bra, apply ice packs, and avoid nipple stimulation
For non-breastfeeding clients, engorgement is managed by wearing a snug bra, applying cold compresses, and avoiding stimulation that triggers further milk production.
Question 6: A nurse is assessing a postpartum client's Homans' sign. Which statement about this assessment is accurate?
- A positive Homans' sign definitively diagnoses DVT
- Homans' sign is an unreliable indicator and DVT requires further diagnostic testing (Correct answer)
- Calf pain on dorsiflexion rules out pulmonary embolism
- Homans' sign is assessed by flexing the knee against resistance
Correct answer: Homans' sign is an unreliable indicator and DVT requires further diagnostic testing
Homans' sign has poor sensitivity and specificity for DVT; a positive finding warrants Doppler ultrasound for definitive diagnosis.
Question 7: A postpartum client reports passing a plum-sized clot. After assessing the fundus is firm, what should the nurse do next?
- Document as a normal finding and continue monitoring
- Notify the physician and save the clot for evaluation (Correct answer)
- Administer methylergonovine (Methergine) immediately
- Perform a vaginal exam to check for lacerations
Correct answer: Notify the physician and save the clot for evaluation
Clots larger than a quarter (golf-ball or plum-sized) are abnormal and should be reported to the provider and saved for quantification.
