M Newborn

Level of Cognitive Ability: Analyzing; Client Needs:
Physiological Integrity; Content Area: Maternity: Postpartum; Priority

Concepts: Infection, Reproduction
1. The nurse is caring for a postpartum client. Which finding should make the nurse suspect endometritis in this client?
 1. Breast engorgement
 2. Elevated white blood cell count
 3. Lochia rubra on the second day postpartum
 4. Fever over 38° C, beginning 2 days postpartum
Rationale:
Endometritis is a common cause of postpartum infection. The presence of fever of 38° C or more on 2 successive days of the first 10
postpartum days (not counting the first 24 hours after birth) is indicative of a postpartum infection. Breast engorgement is a normal response
in the postpartum period and is not associated with endometritis. The white blood cell count of a postpartum woman is normally elevated;
thus, this method of detecting infection is not of great value in the puerperium. Lochia rubra on the second day postpartum is a normal
finding. McKinney et al (2013), pp. 678-679
Test-Taking Strategy:
Focus on the subject, endometritis. Recalling the normal findings in the postpartum period will assist in eliminating options 1, 2, and 3.
Review:
The signs of endometritis.
Priority Nursing Tip:
A postpartum infection may also be termed a puerperal infection and is described as an infection of the genital canal that occurs within 28
days after a miscarriage, induced abortion, or childbirth.
Level of Cognitive Ability: Analyzing; Client Needs: Physiological Integrity; Content Area: Maternity: Postpartum; Priority
Concepts: Nutrition, Reproduction
2. The nurse in the postpartum unit is assessing a newborn for signs of breast-feeding problems. Which findings indicate a problem? Select all
that apply.
 1. The infant exhibits dimpling of the cheeks.
 2. The infant makes smacking or clicking sounds.
 3. The mother's breast gets softer during a feeding.
 4. Milk drips from the mother's breast occasionally.
 5. The infant falls asleep after feeding less than 5 minutes.
 6. The infant can be heard swallowing frequently during a feeding.
Rationale:
It is important for the nurse to identify breast-feeding problems while the mother is hospitalized so that the nurse can teach the mother how
to prevent and treat any problems. Infant signs of breast-feeding problems include dimpling of the cheeks; making smacking or clicking
sounds; falling asleep after feeding less than 5 minutes; refusing to breast-feed; tongue thrusting; failing to open the mouth at latch-on;
turning the lower lip in; making short, choppy motions of the jaw; and not swallowing audibly. Softening of the breast during feeding,
noting milk in the infant's mouth or dripping from the mother's breast occasionally, and hearing the infant swallow are signs that the infant
is receiving breast milk. McKinney et al (2013), p. 539
Focus on the subject, signs of breast-feeding problems. Think about the process of feeding and visualize the effect of each observation
identified in the options. This will direct you to the correct options.
Review:
The signs of breast-feeding problems.
If the mother is breast-feeding, calorie needs increase by 200 to 500 calories per day; increased fluids and the continuance of prenatal
vitamins and minerals are important.
Concepts: Clinical Judgment, Reproduction
3. It has been 12 hours since the client's delivery of a newborn. The nurse assesses the client for the process of involution and documents that
it is progressing normally when palpation of the client's fundus is at which level?
 1. At the level of the umbilicus
 2. One fingerbreadth below the umbilicus
 3. Two fingerbreadths below the umbilicus
 4. Midway between the umbilicus and the symphysis pubis
Rationale:
The term "involution" is used to describe the rapid reduction in size and the return of the uterus to a normal condition similar to its
nonpregnant state. Immediately after the delivery of the placenta, the uterus contracts to the size of a large grapefruit. The fundus is situated
in the midline between the symphysis pubis and the umbilicus. Within 6 to12 hours after birth, the fundus of the uterus rises to the level of
the umbilicus. The top of the fundus remains at the level of the umbilicus for about a day and then descends into the pelvis approximately
one fingerbreadth on each succeeding day. Lowdermilk, Perry, Cashion, Alden (2012), pp. 478-479
Focus on the subject, 12 hours after birth. Visualize the process of assessment of involution and the expected finding at this time to answer
the question.
Review:
The process of involution.
By approximately 10 days postpartum, the uterus cannot be palpated abdominally.
Level of Cognitive Ability: Evaluating; Client Needs: Physiological Integrity; Content Area: Maternity: Postpartum; Priority
Concepts: Client Education, Reproduction
1. The nurse teaches a postpartum client about observation of lochia. The nurse determines the client's understanding when the client says that
on the second day postpartum, the lochia should be which color?
 1. Red
 2. Pink
 3. White
 4. Yellow
Rationale:
The uterus rids itself of the debris that remains after birth through a discharge called lochia, which is classified according to its appearance
and contents. Lochia rubra is dark red in color. It occurs from delivery to 3 days postpartum and contains epithelial cells, erythrocytes,
leukocytes, shreds of decidua, and occasionally fetal meconium, lanugo, and vernix caseosa. Lochia serosa is a brownish pink discharge that
occurs from days 4 to 10. Lochia alba is a white discharge that occurs from days 10 to 14. Lochia should not be yellow in color or contain
large clots; if it does, the cause should be investigated without delay. McKinney et al (2013), pp. 360, 434-435
Focus on the subject, lochia. Noting the words "second day postpartum" will direct you to the correct option.
Review:
The normal postpartum assessment findings for lochia discharge.
The amount of lochial discharge may increase with ambulation.
Level of Cognitive Ability: Applying; Client Needs: Safe and Effective Care Environment; Content Area: Maternity: Postpartum; Priority
Concepts: Client Education, Safety
1. After delivery, the postpartum nurse instructs the client with known cardiac disease to call for the nurse when she needs to get out of bed or
when she plans to care for her newborn infant. Which rationale is the basis for these instructions?
 a. Help the mother assume the parenting role.
 b. Minimize the potential of postpartum hemorrhage.
 c. Provide an opportunity for the nurse to teach newborn infant care techniques.
 d. Avoid maternal or infant injury caused by the potential for syncope or overexertion.
Rationale:
The immediate postpartum period is associated with increased risks for the cardiac client. Hormonal changes and fluid shifts from
extravascular tissues to the circulatory system cause additional stress on cardiac functioning. Although options 1, 2, and 3 are appropriate
nursing concerns during the postpartum period, the primary concern for the cardiac client is to maintain a safe environment because of the
potential for cardiac compromise. McKinney et al (2013), pp. 620-621
Focus on the subject, safety for the postpartum mother with cardiac disease. Option 4 is the only option that relates directly to the subject of
safety.
Review:
The physiological manifestations that occur in a postpartum cardiac client and the need to implement safety precautions.
Monitor the postpartum client with cardiac disease closely for signs and symptoms of cardiac stress and decompensation. These include
cough, fatigue, dyspnea, chest pain, and tachycardia.
Level of Cognitive Ability: Evaluating; Client Needs: Health Promotion and Maintenance; Content Area: Maternity: Postpartum; Priority
Concepts: Client Education, Health Promotion
2. The nurse provides instructions to a new mother who is about to breast-feed her newborn infant. The nurse observes the new mother as she
breast-feeds for the first time and determines the mother needs further teaching if the new mother applies which technique?
 1. Turns the newborn infant on his side, facing the mother
 2. Tilts up the nipple or squeezes the areola, pushing it into the newborn's mouth
 3. Draws the newborn the rest of the way onto the breast when the newborn opens his mouth
 4. Places a clean finger in the side of the newborn's mouth to break the suction before removing the newborn from the breast
Rationale:
The mother is instructed to avoid tilting up the nipple or squeezing the areola and pushing it into the newborn's mouth; doing so does not
facilitate the breast-feeding process or the flow of milk. Options 1, 3, and 4 are correct procedures for breast-feeding. McKinney et al
(2013), pp. 536-537
Note the strategic words, needs further teaching. This creates a negative event query and asks you to select the incorrect client action.
Visualize the descriptions in each of the options. This will eliminate options 1, 3, and 4. Also, carefully reading option 2 and noting the
word pushing, which suggests force or resistance, should assist with directing you to this option.
Review:
The procedure for breast-feeding.
A breast-fed infant's stools are usually light yellow, seedy, watery, and frequent.
Concepts: Client Education, Infection
3. The nurse has provided instructions to a new mother with a urinary tract infection regarding foods and fluids to consume that will acidify
the urine. The nurse determines that further teaching is needed if the mother indicates that which fluid will acidify the urine?
 1. Prune juice
 2. Apricot juice
 3. Cranberry juice
 4. Carbonated drinks
Rationale:
Acidification of the urine inhibits the multiplication of bacteria. Carbonated drinks should be avoided because they increase urine alkalinity.
Fluids that acidify the urine include prune, apricot, and cranberry juice. McKinney et al (2013), p. 680
Note the strategic words, further teaching is needed. These words indicate a negative event query and ask you to select the fluid item that
will not acidify the urine. Note the similarity between options 1, 2, and 3 in that these items are fruit juices. This will assist with directing
you to the correct option.
Review:
The foods and fluids that cause urine acidification.
In addition to apricots, prunes, and cranberries, other foods that acidify the urine include tomatoes, meat, fish, oysters, poultry, corn,
legumes, cheese, eggs, and whole grains.
Level of Cognitive Ability: Applying; Client Needs: Health Promotion and Maintenance; Content Area: Maternity: Postpartum; Priority
Concepts: Clinical Judgment, Collaboration
1. The nurse is preparing to care for the mother of a preterm infant. When should the nurse plan to begin discharge planning?
 1. When the mother is in labor
 2. When the discharge date is set
 3. After stabilization of the infant during the early stages of hospitalization
 4. When the parents feel comfortable with and can demonstrate adequate care of the infant
Rationale:
Discharge planning begins at admission. The determination of the services, needs, supplies, and equipment requirements should not be
made on the day of discharge. Option 1 is incorrect because during labor, the outcome of the delivery is not known. Options 2 and 4 are
incorrect because these times are much too late to make the plans that need to be made. McKinney et al (2013), p. 691
Note the subject, discharge planning for a mother of a preterm infant. Remember that discharge planning always begins at admission to the
hospital. Noting the words early stages of hospitalization will direct you to the correct option.
Review:
The guidelines related to discharge planning.
A case manager is a nurse who assumes responsibility for coordinating the client's care at admission and after discharge.
Level of Cognitive Ability: Analyzing; Client Needs: Health Promotion and Maintenance; Content Area: Maternity: Postpartum; Priority
103. The nurse is developing goals for the postpartum client who is at risk for uterine infection. Which goal would be most appropriate for this
client?
 1. The client will verbalize a reduction of pain.
 2. The client will report how to treat an infection.
 3. The client will be able to identify measures to prevent infection.
 4. The client will identify the presence of Braxton Hicks contractions.
Rationale:
The uterus is theoretically sterile during pregnancy until the membranes rupture. However, it is capable of being invaded by pathogens after
membrane rupture. Options 1 and 4 are unrelated to the subject of infection. Option 2 indicates that an infection is present. Option 3 is a
goal for the client who is at risk for infection. McKinney et al (2013), pp. 682-683
Focus on the strategic words, most appropriate. Noting the word prevent in option 3 will direct you to this option. Options 1 and 4 are
unrelated to the subject of the question, a client at risk for uterine infection. Option 2 implies that an infection has been diagnosed.
Review:
The goals for a client who is at risk for uterine infection.
In the postpartum client, a temperature of 100.4° F or greater after 24 hours postpartum indicates infection.
Concepts: Client Education, Infection
2. A neonatal intensive care unit (NICU) nurse teaches hand washing techniques to the parents of an infant who is receiving antibiotic
treatment for a neonatal infection. The nurse determines that the parents understand the primary purpose of hand washing if which
statement is made?
 1. "It is primarily done to reduce their fears."
 2. "It is primarily done to minimize the spread of infection to other siblings."
 3. "It is primarily done to allow them an opportunity to communicate with each other and staff."
 4. "It is primarily done to reduce the possibility of transmitting an environmental infection to the infant."
Rationale:
Appropriate hand washing by staff and parents has been effective for the prevention of nosocomial infections in nursery units. This action
also promotes parents taking an active part in the care of their infant. Options 1 and 3 are not the primary reasons to perform hand washing.
Because the infant has the infection and is in the NICU, option 2 is incorrect. McKinney et al (2013), p. 920
Note the strategic word, primary, to assist you in eliminating options 1 and 3. Noting that the infant is in the NICU will assist you in
eliminating option 2.
Review:
The purposes of hand washing
Hand washing is the first line of defense against the spread of microorganisms.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Maternity: Postpartum; Priority
Concepts: Glucose Regulation, Reproduction
2. A postpartum client with gestational diabetes is scheduled for discharge. During the discharge teaching, the client asks the nurse, "Do I have
to worry about this diabetes anymore?" Which is the appropriate response by the nurse?
 1. "Your blood glucose level is within normal limits now, so you will be all right."
 2. "You will only have to worry about the diabetes if you become pregnant again."
 3. "You will be at risk for developing gestational diabetes with your next pregnancy and also for developing diabetes mellitus."
 4. "When you have gestational diabetes, you have diabetes forever, and you must be treated with medication for the rest of your
life."
Rationale:
The client is at risk for developing gestational diabetes with each pregnancy. The client also has an increased risk for developing diabetes
mellitus and needs to comply with follow-up assessments. She also needs to be taught techniques to lower her risk for developing diabetes
mellitus, such as weight control. The diagnosis of gestational diabetes mellitus indicates that this client has an increased risk for developing
diabetes mellitus; however, with proper care, it may not develop. Lowdermilk, Perry, Cashion, Alden (2012), p. 704
Note the subject, the long-term effect of gestational diabetes. In addition, use therapeutic communication techniques to answer the
question and direct you to the correct option.
Review:
Gestational diabetes.
Pregnant women should be screened for gestational diabetes between 24 and 28 weeks of pregnancy. Insulin rather than oral hypoglycemic
agents are prescribed for use during pregnancy.
Level of Cognitive Ability: Analyzing; Client Needs: Psychosocial Integrity; Content Area: Maternity: Postpartum; Priority
Concepts: Caregiving, Coping
1. The nurse is planning care for a client with an intrauterine fetal demise. Which is an inappropriate goal for this client?
 1. The woman and her family will discuss plans for going home without the infant.
 2. The woman and her family will express their grief about the loss of their desired infant.
 3. The woman will recognize that thoughts of worthlessness and suicide are normal after a loss.
 4. The woman and her family will contact their pastor or grief counselor for support after discharge.
Rationale:
It is important for the nurse to assess whether the client is undergoing the normal grieving process. Signs that are a cause for concern and
that are not part of the normal grieving process include thoughts of worthlessness and suicide. Options 1, 2, and 4 are appropriate goals.
Lowdermilk, Perry, Cashion, Alden (2012), pp. 932-934
Focus on the subject, an inappropriate goal. These words should direct you to option 3 because thoughts of worthlessness and suicide are
causes for concern.
Review:
The psychosocial care of the client who has experienced intrauterine fetal demise.
For the client with intrauterine fetal demise, there is a risk for disseminated intravascular coagulation (DIC).
Concepts: Caregiving, Coping
3. A client has just given birth to a newborn who has a cleft lip and palate. When planning to talk to the client, the nurse recognizes that the
client needs to first work through which emotion before maternal bonding can occur?
 1. Guilt
 2. Grief
 3. Anger
 4. Depression
Rationale:
The nurse should recognize that a mother will go through the grief process after giving birth to a child with a birth defect. Following the
grief process, the mother can begin to focus on bonding with the infant. Options 1, 3, and 4 are incorrect because they are each only one
component of the grief process. McKinney et al (2013), pp. 1072-1074
Note the strategic word, first. Options 1, 3, and 4 are incorrect because they are each only one component of the grief process.
Review:
The grief process.
The nurse's role in the grief and loss process includes communicating with the client and family members. The nurse must consider the
client's culture, religion, family structure, individual life experiences, coping skills, and support systems.
Concepts: Coping, Family Dynamics
4. The nurse is observing the parents at the bedside of their small-for-gestational-age (SGA) infant, who was born at 27 weeks' gestation. The
infant's mother states, "She is so tiny and fragile. I'll never be able to hold her with all those tubes." Considering this statement, which
problem should the nurse identify for the mother?
 1. Impaired adjustment
 2. Trouble with family coping
 3. Potential for compromised parenting
 4. Difficulty monitoring signs of respiratory difficulty
Rationale:
Parents of a high-risk neonate, such as a preterm SGA infant, are at risk for compromised parenting. Parent–infant bonding is affected if the
infant does not exhibit normal newborn characteristics. Option 1 involves the nonacceptance of a health status change or an inability to
solve a problem or set a goal. Option 2 involves the identification of trouble with family coping. Option 4 addresses the nurse's role in
caring for the infant. McKinney et al (2013), pp. 704, 711-712
Focus on the subject, the appropriate client problem based on the client's statement. Eliminate option 4 first because this is not a role of the
parent and is a nursing function. Note the words "I'll never be able to hold her." This should assist with directing you to compromised
parenting.
Review:
The psychosocial parental concerns for a small-for-gestational-age infant.
For the infant who is small for gestational age, the nurse must maintain airway patency and cardiopulmonary function and maintain the
infant's body temperature.
Level of Cognitive Ability: Applying; Client Needs: Psychosocial Integrity; Content Area: Maternity: Postpartum; Priority
Concepts: Communication, Pain
5. A client has just delivered a large-for-gestational-age (LGA) infant by the vaginal route. The client verbalizes concern regarding the infant's
facial bruising and causing pain to the site if touched. Which therapeutic statement should the nurse make to alleviate the client's concerns?
 1. "I can show you how to gently stroke the face and not cause pain."
 2. "It is a normal finding in large babies and nothing to be concerned about."
 3. "The bruising is caused by polycythemia, which usually leads to jaundice."
 4. "Because the bruising is painful, it is advisable that you not touch the baby's face."
Rationale:
The mother of an LGA infant with facial bruising may be reluctant to interact with the infant because of concern about causing additional
pain to the infant. The bruising is temporary. Option 2 does not address the mother's verbalized concerns. The LGA infant may have
polycythemia, which can contribute to bruising, but the bruising is not actually caused by the polycythemia. Option 4 advises the mother not
to touch the baby's face because the bruising is painful, but touch is an important component of the attachment process. Touching the infant
gently with the fingertips should be encouraged. Lowdermilk, Perry, Cashion, Alden (2012), p. 508; McKinney et al (2013), pp. 704, 712
Note the subject, causing pain to infant's facial bruising if touched and alleviating the client's concern. Eliminate options 2 and 3 first
because they do not specifically address the subject of touch. From the remaining options, note the relationship of the word touch in the
question and the word stroke in the correct option.
Review:
Mother–infant bonding.
For the infant that is large for gestational age, the nurse should monitor vital signs, monitor blood glucose levels and for signs of
hypoglycemia, and initiate early feedings.
Concepts: Clotting, Reproduction
6. The nurse is caring for a postpartum client with thromboembolytic disease. Which intervention is most important to include when planning
care to prevent the complication of pulmonary embolism?
 1. Enforce bedrest.
 2. Monitor the vital signs frequently.
 3. Assess the breath sounds frequently.
 4. Administer prescribed anticoagulant therapy.
Rationale:
The purposes of anticoagulant therapy for the treatment of thromboembolytic disease are to prevent the formation of a clot and to prevent a
clot from moving to another area, thus preventing pulmonary embolism. Although options 1, 2, and 3 may be implemented for a client with
thromboembolytic disease, option 4 will specifically assist in the prevention of pulmonary embolism. McKinney et al (2013), p. 677
Note the strategic words, most important. Focus on the subject, preventing the complication of pulmonary embolism. Recall that
anticoagulant therapy is prescribed to treat thromboembolytic disease.
Review:
The interventions for the client with thromboembolytic disease that will prevent pulmonary embolism.
Medications containing aspirin should not be given to clients receiving anticoagulant therapy, because aspirin prolongs the clotting time and
increases the risk of bleeding.
Level of Cognitive Ability: Applying; Client Needs: Physiological Integrity; Content Area: Maternity: Postpartum; Priority
7. The nurse is checking the fundus of a postpartum woman and notes that the uterus is soft and spongy. Which nursing action is
appropriate initially?
 1. Notify the health care provider.
 2. Encourage the mother to ambulate.
 3. Massage the fundus gently until it is firm.
 4. Document fundal position, consistency, and height.
Rationale:
If the fundus is boggy (soft), it should be massaged gently until it is firm and the client is observed for increased bleeding or clots. Option 2
is an inappropriate action at this time. The nurse should document the fundal position, consistency, and height; the need to perform fundal
massage; and the client's response to the intervention. The health care provider will need to be notified if uterine massage is not helpful.
McKinney et al (2013), p. 668
Note the strategic word, initially. Note the relationship of the data in the question (soft and spongy) and the data in the correct option
(massage the fundus gently until it is firm).
Review:
The nursing interventions related to uterine atony.
The nurse needs to gently massage the fundus of a client experiencing uterine atony and take care not to overmassage.
3. A goal for a postpartum client has been developed that states, "The client will remain free of infection during her hospital stay." Which
assessment data would support that the goal has been met?
 1. Loss of appetite
 2. Absence of fever
 3. Presence of chills
 4. Abdominal tenderness
Rationale:
Fever is the first indication of an infection. Therefore, the absence of a fever indicates that an infection is not present. Loss of appetite,
chills, and abdominal tenderness can indicate the presence of an infection. McKinney et al (2013), p. 682
Focus on the subject, the physical indications of an infection. The question is asking for a means of evaluating the effectiveness of a goal
that relates to infection. Options 1, 3, and 4 indicate possible signs of infection and that the goal has not been met.
Review:
The signs of postpartum infection.
In the postpartum client, a temperature up to 100.4° F is normal due to the dehydrating effects of labor.
4. A 10-day postpartum breast-feeding client telephones the postpartum unit complaining of a reddened, painful breast and elevated
temperature. Based on assessment of the client's complaints, which action should the nurse tell the client to do?
 1. "Breast-feed only with the unaffected breast."
 2. "Stop breast-feeding because you probably have an infection."
 3. "Notify your health care provider because you may need medication."
 4. "Continue breast-feeding because this is a normal response in breast-feeding mothers."
Rationale:
Based on the signs and symptoms presented by the client (particularly the elevated temperature), the health care provider needs to be
notified because an antibiotic that is tolerated by the infant, as well as the mother, may be prescribed. The mother should continue to nurse
on both breasts, but should start the infant on the unaffected breast while the affected breast lets down. Lowdermilk, Perry, Cashion, Alden
(2012), p. 629; McKinney et al (2013), p. 541
Focus on the subject, breast-feeding with a reddened, painful breast, and elevated temperature. Option 4 can be eliminated first because the
client's complaints are not normal. Eliminate option 2 because it does not encourage the continuation of breast-feeding or notification of the
health care provider. Option 1 also does not encourage continuation of normal breast-feeding and could possibly lead to engorgement,
creating more discomfort and pain for the mother.
Review:
Postpartum complications.
Medications, including over-the-counter medications, need to be avoided in the breast-feeding mother unless prescribed, because they may
be unsafe when breast-feeding.
Concepts: Client Education, Health Promotion
4. A mother who is breast-feeding her newborn infant is experiencing nipple soreness, and the nurse provides teaching regarding measures to
relieve the soreness. Which statement by the mother indicates an understanding of the teaching?
 1. "I need to avoid rotating breast-feeding positions so that the nipple will toughen."
 2. "I need to stop nursing during the period of nipple soreness to allow the nipples to heal."
 3. "I need to nurse less frequently and substitute a bottle feeding until the nipples become less sore."
 4. "I need to position my infant with her ear, shoulder, and hip in straight alignment and place her stomach against me."
Rationale:
Comfort measures for nipple soreness include positioning the infant with the ear, shoulder, and hip in straight alignment and with the
infant's stomach against the mother's. Additional measures include rotating breast-feeding positions, breaking suction with the little finger,
nursing frequently, beginning feeding on the less sore nipple, not allowing the infant to chew on the nipple or to sleep holding the nipple in
the mouth, and applying tea bags soaked in warm water to the nipple. Options 1, 2, and 3 are incorrect client statements. McKinney et al
(2013), pp. 542-543
Focus on the subject, nipple soreness with breast-feeding. Note the words indicates an understanding. Visualize each of the options in
terms of how it may or may not lessen the nipple soreness to direct you to option 4.
Review:
The measures to reduce nipple soreness in a mother who is breast-feeding.
The nurse needs to assess the newborn's ability to attach to the mother's breast and suck.
5. The nurse is performing an assessment on a mother who just delivered a healthy newborn. When checking the uterine fundus the nurse
should expect to note that the fundus is positioned at which location?
 1. To the right of the abdomen
 2. At the level of the umbilicus
 3. Above the level of the umbilicus
 4. One fingerbreadth above the symphysis pubis
Rationale:
Immediately after delivery, the uterine fundus should be at the level of the umbilicus or one to three fingerbreadths below it and in the
midline of the abdomen. A fundus that is not located in the midline may indicate a full bladder. If the fundus is above the umbilicus, this
may indicate that blood clots in the uterus need to be expelled by fundal massage. McKinney et al (2013), p. 441
Focus on the subject, position of the uterine fundus postdelivery. Note the words just delivered. Use knowledge regarding normal anatomy
and visualize each description in the options to direct you to the correct option.
Review:
Uterine fundus positions.
The postpartum period starts immediately after delivery and is usually completed by week 6 after delivery.
Concepts: Reproduction, Thermoregulation
8. The nurse obtains the vital signs on a mother who delivered a healthy newborn 2 hours ago and notes that the mother's temperature is 102°
F. What is the appropriate nursing action at this time?
 1. Notify the health care provider.
 2. Remove the blanket from the client's bed.
 3. Document the finding and recheck the temperature in 4 hours.
 4. Administer acetaminophen (Tylenol) and recheck the temperature in 4 hours.
Rationale:
Vital signs usually return to normal within the first hour postpartum if no complications arise. A slight elevation in the temperature may be
noted if the client is experiencing dehydrating effects that can occur from labor. A temperature of 102° F indicates infection, and the health
care provider should be notified. Options 2, 3, and 4 are inaccurate nursing interventions for a temperature of 102° F 2 hours after delivery.
Focus on the subject, temperature of 102° F 2 hours postdelivery. Note that the mother delivered 2 hours ago. Think about the normal
postpartum findings. It is most appropriate in this situation to report the findings because a temperature of 102° F can indicate infection.
Review:
Normal vital signs after delivery.
A temperature of 100.4° F is normal during the first 24 hours postpartum because of dehydration, a temperature of 100.4° F or greater after
24 hours postpartum indicates infection.
Concepts: Perfusion, Reproduction
6. The nurse in the postpartum unit is caring for a mother after vaginal delivery of a healthy newborn. The client received epidural anesthesia
for the delivery. One-half hour after admission to the postpartum unit, the nurse checks the client and suspects the presence of a vaginal
hematoma. Which finding would be the best indicator of the presence of this type of hematoma?
 1. Changes in vital signs
 2. Signs of vaginal bruising
 3. Client complaints of a tearing sensation
 4. Client complaints of intense vaginal pressure
Rationale:
Changes in vital signs indicate hypovolemia in the anesthetized postpartum woman with a vaginal hematoma. Vaginal bruising may be
present, but this may be a result of the delivery process and additionally is not the best indicator of the presence of a hematoma. Because the
client received anesthesia, she would not feel pain or pressure. McKinney et al (2013), pp. 670-671
Focus on the subject, vaginal hematoma and signs and symptoms, and note the strategic word, best. Noting that the client received an
epidural anesthetic will assist in eliminating options 3 and 4. From the remaining choices, recalling the pathophysiology associated with the
development of a hematoma and use of the ABCs—airway, breathing, and circulation—will direct you to the correct option.
Review:
The signs of a vaginal hematoma.
Monitor the postpartum client for abnormal pain or perineal pressure, especially when forceps delivery has occurred.
Concepts: Health Promotion, Safety
5. A rubella vaccine is administered to a client who delivered a healthy newborn 2 days ago. The nurse provides instructions to the client
regarding the potential risks associated with this vaccination. Which statement by the client indicates an understanding of the medication?
 1. "I need to stay out of the sunlight for 3 days."
 2. "The injection site may itch, but I can scratch it if I need to."
 3. "I need to avoid sexual intercourse for 2 to 3 months after the vaccination."
 4. "I need to prevent becoming pregnant for 2 to 3 months after the vaccination."
Rationale:
Rubella vaccine is a live attenuated virus that evokes an antibody response and provides immunity for approximately 15 years. Because
rubella is a live vaccine, it will act as the virus and is potentially teratogenic in the organogenesis phase of fetal development. The client
needs to be informed about the potential effects this vaccine may have and the need to avoid becoming pregnant for a period of 2 to 3
months afterward. Sunlight has no effect on the person who is vaccinated. The vaccine may cause local or systemic reactions, but all are
mild and short-lived. Abstinence from sexual intercourse is not necessary, unless another form of effective contraception is not being used.
McKinney et al (2013), pp. 439-440
Focus on the subject, a rubella vaccine. Recall the effect of live vaccines on pregnancy and fetal development. Remembering that viruses
can cross the placental barrier will direct you to the correct option.
Review:
The potential risks rubella vaccine.
Individuals who are immunocompromised should not receive the Rubella vaccine.
Concepts: Health Promotion, Pain
6. A new breast-feeding mother is seen in the clinic with complaints of breast discomfort. The nurse determines that the mother is
experiencing breast engorgement and provides the mother with instructions regarding care for the condition. Which statement by the mother
indicates an understanding of the measures that will provide comfort for the engorgement?
 1. "I will breast-feed using only one breast."
 2. "I will apply cold compresses to my breasts."
 3. "I will avoid the use of a bra while my breasts are engorged."
 4. "I will massage my breasts before feeding to stimulate letdown."
Rationale:
Comfort measures for breast engorgement include massaging the breasts before feeding to stimulate letdown, alternating the breasts during
feeding, taking a warm shower or applying warm compresses just before feeding, and wearing a supportive well-fitting bra at all times.
Options 1, 2, and 3 are incorrect measures. McKinney et al (2013), pp. 541, 543
Focus on the subject, breast engorgement. Visualize each of the descriptions in the options to assist in directing you to the correct option.
Review:
The measures to alleviate breast engorgement.
The postpartum client who is breast-feeding should not use soap on the breasts because it tends to remove natural oils, which increases the
chance of cracked nipples.
Concepts: Inflammation, Reproduction
4. A home care nurse provides instructions to a breast-feeding postpartum client who has developed breast engorgement. Which measure
should the nurse tell the client to take?
 1. Avoid the use of a bra during engorgement.
 2. Apply cool packs to both breasts for 20 minutes before a feeding.
 3. Gently massage the breast from the outer areas to the nipple during feeding.
 4. Feed the infant less frequently, every 4 to 6 hours, and use bottle-feeding in between.
Rationale:
The client with breast engorgement should be advised to breast-feed frequently, at least every 2½ hours for 15 to 20 minutes per side. Moist
heat should be applied to both breasts for about 20 minutes before a feeding. Between feedings, the mother should wear a supportive bra.
During a feeding, it is helpful to gently massage the breast from the outer areas to the nipple to stimulate the let-down and flow of milk.
Focus on the subject, breast engorgement. Think about the manifestations that occur with engorgement, and recall that measures are
initiated to facilitate the flow of milk. With this concept in mind, eliminate options 1, 2, and 4, because they will not facilitate the flow of
milk.
Review:
Measures that are used for breast engorgement.
Encourage the client with breast engorgement to wear a support bra at all times, even when sleeping.
Level of Cognitive Ability: Analyzing; Client Needs: Health Promotion and Maintenance; Content Area: Maternity: Postpartum; Priority
Concepts: Reproduction, Sexuality
9. The nurse is discussing contraceptive methods with a postpartum client. The nurse tells the client that combined oral contraceptives are
contraindicated if the client has a medical history of which conditions? Select all that apply.
 1. Acne
 2. Infertility
 3. Breast cancer
 4. Dysmenorrhea
 5. Coronary artery disease
 6. Thromboembolic disorders
Rationale:
Contraindications for combined oral contraceptive (COC) use include a history of breast cancer, coronary artery disease, and
thromboembolic disorders. The use of oral contraceptives is also contraindicated in a client with impaired liver function, liver tumor,
smoking (if the client is more than 35 years old and smokes more than 15 cigarettes a day), headaches with focal neurological symptoms,
surgery with prolonged immobilization or any surgery on the legs, hypertension, and diabetes mellitus (of more than 20 years' duration)
with vascular disease. COC is not contraindicated for a client who has a history of infertility. COC is not contraindicated with
dysmenorrhea, although dysmenorrhea may be a side effect of therapy. COC is sometimes used to treat acne. McKinney et al (2013), p. 745
Focus on the subject, contraindications to the use of COC. Recall the contraindications, uses, and side effects of COC to direct you to the
correct options. Remember that the correct options to this question are disorders that would contraindicate the use of COC. Option 4 is a
side effect but not a contraindication. COC is sometimes used to treat acne, and it is not contraindicated for clients with infertility.
Review:
Combined oral contraceptive (COC) use.
Oral contraceptives contain a combination of estrogen and a progestin or a progestin alone. Medications that contain only progestin are less
effective than the combined medications.
7. The nurse in the postpartum unit is reviewing the records of the clients on the unit. During the review, the nurse determines that which
client is most at risk for developing endometritis following delivery?
 1. A primigravida with a normal spontaneous vaginal delivery
 2. A gravida 2 who delivered vaginally following an 18-hour labor
 3. A woman experiencing an elective cesarean delivery at 38 weeks' gestation
 4. An adolescent experiencing an emergency cesarean delivery for fetal distress
Rationale:
Endometritis is an acute infection of the mucous lining of the uterus that can occur immediately after delivery. Cesarean delivery is the
primary risk factor for uterine infection, especially after emergency procedures. Other risk factors include prolonged rupture of the
membranes, multiple vaginal exams, and an excessive length of labor. Options 1, 2, and 3 do not describe the client "most at risk" to
develop endometritis following delivery. Lowdermilk et al (2012), p. 834
Focus on the subject, risk for developing endometritis. Note the strategic word, most, in the query of the question. Recalling that cesarean
delivery is a primary risk factor will eliminate options 1 and 2. From the remaining options, noting the word, emergency, will direct you to
the correct option.
Review:
Etiology associated with endometritis.
Trichomoniasis can cause endometritis. A normal saline wet smear of vaginal secretions is checked for protozoa to determine the presence
of this infection.
8. The postpartum nurse is assigned to admit a client to the postpartum unit following delivery of a viable newborn. In the report, the nurse is
told that the client had a placenta previa. Which complication should the nurse monitor for as the priority for this client?
 1. Hemorrhage
 2. Excess fluid volume
 3. Deficient fluid volume
 4. Impaired urinary elimination
Rationale:
In placenta previa, the placenta is implanted in the lower uterine segment and does not contain the same intertwining musculature as the
fundus of the uterus; however, this site is more prone to bleeding. Options 2 and 4 may also be appropriate but are not specifically related to
placenta previa. Option 3 is also unrelated to placenta previa. McKinney et al (2013), p. 584
Focus on the subject, placenta previa, and the strategic word, priority. Thinking about the normal physiology of the uterus and the site of
implantation of a placenta previa will direct you to option 1.
Review:
Complications associated with placenta previa.
It is important to know the differences between placenta previa and abruptio placentae. In placenta previa, there is painless, bright red
vaginal bleeding, and the uterus is soft, relaxed, and nontender. In abruptio placentae, there is dark red vaginal bleeding, uterine pain or
tenderness or both, and uterine rigidity.
10. The postpartum nurse is caring for a mother following delivery of her newborn. The nurse checks the perineum on the mother and notes a
trickle of bright red blood coming from the perineum. The nurse checks the client's fundus and notes that it is firm. On review of the client's
record, the nurse also notes that an episiotomy was performed. Based on this data, which determination should the nurse make?
 1. This is a normal expectation following episiotomy.
 2. The mother should be allowed bathroom privileges only.
 3. The perineal check should be performed more frequently.
 4. The bright red bleeding is abnormal and should be reported.
Rationale:
Lochial flow should be distinguished from bleeding originating from a laceration or episiotomy, which is usually brighter red than lochia,
and presents as a continuous trickle of bleeding even though the fundus of the uterus is firm. This bright red bleeding is abnormal and needs
to be reported. Options 1, 2, and 3 are incorrect interpretations of the data. McKinney et al (2013), p. 360
Note that there is some normal data presented in the question. Also focus on the subject, abnormal findings, and the words, bright red
blood. Bright red blood indicates active bleeding. This is an indication that the flow is not normal.
Review:
Lochial flow and complications associated with episiotomy.
In order to prevent complications for the client with an episiotomy, the nurse should instruct the client to administer perineal care after each
voiding; use an analgesic spray as prescribed, and take analgesics as prescribed if other comfort measures are unsuccessful.
Level of Cognitive Ability: Understanding; Client Needs: Physiological Integrity; Content Area: Maternity: Postpartum; Priority
5. The nursing student is assigned to care for a postpartum client. The registered nurse reviews the nursing care plan developed by the student
and asks the student to describe the process of involution. Which response by the student indicates an accurate description of this process?
 1. "Involution refers to an inverted uterus, which is beginning to return to normal."
 2. "Involution refers to the gradual reversal of the uterine muscle into the abdominal cavity."
 3. "Involution refers to the descent of the uterus into the pelvic cavity occurring at a rate of 3 centimeters daily."
 4. "Involution is a progressive descent of the uterus into the pelvic cavity occurring approximately 1 centimeter per day."
Rationale:
Involution is a progressive descent of the uterus into the pelvic cavity. After birth, descent occurs at a rate of approximately 1 fingerbreadth
or approximately 1 cm per day. Options 1, 2, and 3 are incorrect descriptions of the process of involution. McKinney et al (2013), p. 448
Focus on the subject, involution. Use specific knowledge of medical terminology to assist in defining the word, involution, and selecting
the correct option.
Review:
Involution.
Clients who breast-feed may experience a more rapid involution because of the release of oxytocin during breast-feeding.
9. A mother who is 2 days postpartum should be routinely assessed by the nurse for thrombophlebitis by specifically checking which
parameter?
 1. Pain in the calf area
 2. Intake and output values
 3. Fundal height for its location
 4. Leg circumference for swelling
Rationale:
Pain in the calf area indicates irritation of the blood vessels caused by clot formation and may be indicative of thrombophlebitis. Although
intake and output values may be important information for some conditions, it is not a parameter tied to thrombophlebitis. Although fundal
height is important to assess in the newly delivered mother, it is not directly related to assessment for thrombophlebitis. Checking leg
circumference for swelling is not as accurate an indicator of thrombophlebitis as is calf pain. McKinney et al (2013), pp. 674-675
Focus on the subject, the presence of thrombophlebitis. Eliminate options 2 and 3 first, because they are not directly related to assessment
for thrombophlebitis. From the remaining options, noting the word, specifically, will direct you to the correct option. Pain in the calf area is
specific to thrombophlebitis.
Review:
Postpartum assessments and thrombophlebitis.
Never massage the leg of a client with thrombophlebitis because of the risk of dislodging the clot.
Concepts: Client Education, Reproduction
6. The nurse provides instructions to the postpartum client who has developed breast engorgement. Which instruction should the nurse provide
to this client?
 1. To avoid the use of a bra during engorgement
 2. To apply cool packs to both breasts 20 minutes before a feeding
 3. To feed the infant less frequently, using bottle-feeding in between
 4. To gently massage the breast from the outer areas to the nipple during feeding
Rationale:
During a feeding, it is helpful to gently massage the breast from the outer areas to the nipple to stimulate the let-down and flow of milk.
Between feedings, the mother should wear a supportive bra. Moist heat should be applied to both breasts for about 20 minutes before a
feeding. The client with breast engorgement should be advised to feed frequently, at least every 2.5 hours for 15 to 20 minutes per side.
Lowdermilk et al (2012), pp. 495, 499; McKinney et al (2013), pp. 541, 627-628
Focus on the subject, breast engorgement. Recognizing that milk stasis is the primary reason for this problem assists in identifying that the
correct answer will relate to increasing the milk flow. Breast support, heat rather than cold, and increasing the number of feedings will assist
with resolution of breast engorgement.
Review:
Measures used for breast engorgement.
Analgesics may be prescribed for the client with breast engorgement if comfort measures are unsuccessful in relieving discomfort.
11. The nurse is assigned to provide care to a client in labor and will care for the client throughout labor and into the postpartum period. The
nurse assists in developing a plan of care and determines that which is the priority assessment in the fourth stage of labor?
 1. Encouraging food and fluid intake
 2. Checking the mother's temperature
 3. Assessing the uterine fundus and lochia
 4. Providing privacy for the parents and their newborn infant
Rationale:
The fourth stage of labor is the stage of physical recovery for the mother and newborn infant. It lasts from the delivery of the placenta
through the first 1 to 4 hours after birth. A potential complication following delivery is hemorrhage. The most significant source of bleeding
is the site where the placenta is implanted. It is critical that the uterus remain contracted and that vaginal blood flow is monitored every 15
minutes for the first 1 to 2 hours. Although options 1, 2, and 4 are also interventions during this stage, they are not the priority. McKinney
et al (2013), pp. 333, 335
Note the strategic word, priority. Use the ABCs—airway, breathing, and circulation—to direct you to the correct option. Assessing
uterine position and consistency and the amount and character of lochia provide information about blood loss and circulatory status. Options
1, 2, and 4 are appropriate but are not the priority.
Review:
Nursing assessments in the fourth stage of labor.
Lochia may be moderate in amount and red in color in the fourth stage of labor.
Concepts: Clinical Judgment, Infection
12. A 10-day postpartum breast-feeding client calls the postpartum unit at the hospital to speak to the nurse and complains of a reddened,
painful breast and an elevated temperature. Based on the client's complaints, the nurse should make which statement to the client?
 1. "Breast-feed only with the unaffected breast."
 2. "Stop breast-feeding, because you probably have an infection."
 3. "Notify your health care provider, because you may need medication."
 4. "Continue breast-feeding, because this is a normal response in breast-feeding mothers."
Rationale:
The client's complaints may be indicative of mastitis. Based on the signs and symptoms presented by the client, particularly the elevated
temperature, the health care provider needs to be notified, because an antibiotic that is tolerated by the infant as well as the mother may be
prescribed. The mother should continue to nurse on both breasts but should start the infant on the unaffected breast while the affected breast
lets down. McKinney et al (2013), pp. 680-681
Focus on the subject, postpartal mastitis. Eliminate option 1 first because of the closed-ended word, only. Next, eliminate option 4,
because the client's complaints are not normal. From the remaining options, focus on the client's complaints. Noting that the client has an
elevated temperature will direct you to the correct option.
Review:
Postpartal mastitis.
Encourage the postpartum client to provide support to the breasts by wearing a well-fitted and supportive bra.
Concepts: Immunity, Reproduction
2. The nurse is caring for a woman who is human immunodeficiency virus (HIV)-positive and delivered a newborn infant. In the postpartum
period, which psychosocial assessment should the nurse initially address?
 1. Quality of the relationship with her spouse
 2. Maternal fears related to the newborn's status
 3. Quality of the relationship with her other children
 4. Reactions of extended family to the HIV diagnosis
Rationale:
A mother who is human immunodeficiency virus (HIV)-positive may have many fears, particularly about the status of her newborn infant.
Other fears can include lack of knowledge, loss of ability to breast-feed, others' reactions to the diagnosis, quality of relationships, and
financial fears regarding the cost of HIV treatments. However, the nurse should initially address the mother and the mother's fears. This will
provide the mother with the opportunity to discuss specific issues. McKinney et al (2013), pp. 628-630, 725, 728
Note the strategic word, initially. Options 1 and 3 addressing relationship with spouse and children are comparable or alike and can
therefore be eliminated. Reactions of extended family are not an immediate issue.
Review:
Human immunodeficiency virus (HIV).
Newborns at risk for HIV infection need to receive all recommended immunizations at the regular schedule.
Concepts: Clinical Judgment, Inflammation
10. A breast-feeding mother has developed a temperature of 104° F and is experiencing shaking chills. The nurse further assesses the client for
signs/symptoms of mastitis and observes for which finding?
 1. Bilateral breast engorgement
 2. Scant milk production with bloody discharge
 3. Reddened and extremely tender breast tissue
 4. A hard, warm nodular area in the outer breast quadrant
Rationale:
Reddened, extremely tender breast tissue along with chills and a fever are signs/symptoms of mastitis. Bilateral breast engorgement, scant
milk production with bloody discharge and a hard, warm nodular area in the outer breast quadrant are not signs/symptoms associated with
mastitis. McKinney et al (2013), pp. 680-681
Focus on the subject, mastitis. Recalling that -itis relates to inflammation will direct you to the correct option.
Review:
Signs/symptoms of mastitis.
Mastitis primarily occurs in breast-feeding mothers 2 to 3 weeks after delivery but may occur anytime during lactation.
11. A 2-day postpartum mother complains of severe pain and an intense feeling of swelling and pressure in the vulvar area. After hearing these
complaints, the nurse immediately assesses which client area?
 1. Vulva for hematoma
 2. Vagina for lacerations
 3. Episiotomy for drainage
 4. Rectum for hemorrhoids
Rationale:
Hematoma is suspected when pain or pressure is reported by the client in the vulva area. Massive hemorrhage can occur into the tissues
resulting in hypovolemia and shock; therefore, the client's complaints must be assessed so that interventions may begin immediately. The
client's complaints are not related to options 2, 3, or 4. Vaginal lacerations and hemorrhoids should have been identified much earlier and do
not present with the described findings. Drainage from the episiotomy which would be a sign of infection, does not present with the
signs/symptoms stated in the question. McKinney et al (2013), pp. 669-670
Note the strategic word, immediately. Focus on the subject, feeling of swelling and pressure in the vulvar area 2 days postpartum. Note the
relationship between the word, vulvar, in the question and the word, vulva, in the correct option.
Review:
Signs/symptoms of postpartal hematoma.
Predisposing conditions for hematoma that occurs during the delivery process include operative delivery with forceps or injury to a blood
vessel.
Concepts: Clinical Judgment, Gas Exchange
12. The nurse performs an assessment on a postpartum client who is beginning to experience respiratory distress. The nurse should expect the
client to exhibit which early neurological sign?
 1. Lethargy
 2. Excitement
 3. Withdrawal
 4. Apprehensiveness
Rationale:
Respiratory distress is a fearful event and is likely to cause apprehension. Apprehension can also occur as a result of hypoxia experienced
during the respiratory distress. Lethargy may occur as the respiratory status deteriorates. Excitement and withdrawal are not associated signs
of respiratory distress. Lowdermilk et al (2012), p. 489
Note the strategic word, early, and focus on the subject, respiratory distress. Remember, restlessness and apprehension occur with
respiratory distress.
Review:
Early findings associated with respiratory distress.
The newborn of a mother with diabetes mellitus is at an increased risk for respiratory distress syndrome.
13. The nurse is monitoring a postpartum client for signs of complications. Which finding indicates a sign of potential bleeding?
 1. Multiparity
 2. Prolonged labor
 3. Soft or boggy uterus
 4. Precipitous labor and delivery
Rationale:
Uterine atony accounts for many of the cases of immediate postpartum bleeding. A soft or boggy uterus indicates that the uterus is flaccid
and is a sign of potential bleeding. Options 1, 2, and 4 identify potential risk factors of uterine atony and bleeding or hemorrhage, not an
assessment finding. McKinney et al (2013), pp. 667-668
Focus on the subject, sign of potential bleeding in a postpartum client. Option 3 is the only assessment finding.
Review:
Signs of bleeding in the postpartum period.
One use of oxytocin (Pitocin) is controlling postpartum bleeding. If the nurse determines that the uterus is boggy, she should gently
massage it to restore uterine tone.

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