Assessment
A postpartum nurse assesses a client who is 2 days postpartum. The nurse notes bright red lochia and a foul odor. What is the most appropriate intervention?
A. Document this as a normal finding.
B. Administer prescribed pain medications.
C. Notify the healthcare provider of a potential infection.
D. Instruct the client to change her perineal pad more frequently.
C. Notify the healthcare provider of a potential infection.
A client who is 12 hours postpartum reports that her nipples are sore during breastfeeding. Which intervention should the nurse recommend first?
A. Apply lanolin cream to the nipples after each feeding.
B. Ensure the baby is latching correctly.
C. Use warm compresses on the breasts before feeding.
D. Decrease the frequency of breastfeeding sessions.
B. Ensure the baby is latching correctly.
A client who delivered vaginally reports discomfort in the perineal area. What is the best initial intervention the nurse can provide?
A. Apply an ice pack to the perineal area.
B. Perform a perineal massage.
C. Encourage ambulation.
D. Administer prescribed oral analgesics.
A. Apply an ice pack to the perineal area.
A nurse is caring for a postpartum client who is experiencing heavy bleeding and a boggy uterus. What is the nurse's first action?
A. Notify the healthcare provider immediately.
B. Perform fundal massage.
C. Administer prescribed oxytocin.
D. Check the client’s vital signs.
B. Perform fundal massage.
What nursing intervention is most appropriate to reduce the risk of thrombophlebitis in a postpartum client?
A. Encourage early and frequent ambulation.
B. Administer anticoagulants as prescribed.
C. Restrict fluid intake to prevent edema.
D. Apply compression stockings only if symptoms develop.
A. Encourage early and frequent ambulation.
A postpartum nurse is assessing a client 2 days after delivery. Which type of lochia should the nurse expect to find?
A. Lochia alba
B. Lochia serosa
C. Lochia rubra
D. No lochia
C. Lochia rubra
A client who is breastfeeding reports painful, swollen breasts. What is the nurse’s best initial recommendation?
A. Apply warm compresses before breastfeeding.
B. Pump after each feeding to empty the breasts completely.
C. Use cold packs to reduce swelling after feedings.
D. Decrease the frequency of breastfeeding to reduce milk production.
A. Apply warm compresses before breastfeeding.
A client 8 hours post-cesarean delivery reports 7/10 pain at the incision site. What is the nurse’s priority action?
A. Administer prescribed IV pain medication.
B. Teach relaxation techniques for pain management.
C. Assess the incision for signs of infection.
D. Encourage the client to ambulate to relieve pain.
A. Administer prescribed IV pain medication.
A postpartum nurse is assessing a client 12 hours after delivery. Which finding requires further evaluation?
A. Fundus is firm and located at the level of the umbilicus.
B. Lochia rubra is moderate with small clots.
C. Client reports mild cramping during fundal massage.
D. Calf pain is present with palpation.
D. Calf pain is present with palpation.
A postpartum client continues to have heavy vaginal bleeding despite a firm fundus. What is the most likely cause?
A. Retained placental fragments
B. Uterine atony
C. Endometritis
D. Perineal laceration
A. Retained placental fragments
A postpartum client asks about the expected changes in her lochia. Which response by the nurse is accurate?
A. “Lochia alba is red and typically lasts 1–3 days.”
B. “Lochia serosa is pinkish and occurs around 4–10 days postpartum.”
C. “Lochia rubra is white and appears 2 weeks postpartum.”
D. “Lochia alba is pinkish and appears immediately after delivery.”
B. “Lochia serosa is pinkish and occurs around 4–10 days postpartum.”
A new mother expresses concern that her breasts are not producing enough milk because she only sees a small amount of yellowish fluid. What is the nurse’s best response?
A. “You should consider switching to formula feeding.”
B. “This is colostrum, which is normal and very nutritious for your baby.”
C. “You need to drink more fluids to increase milk production.”
D. “It is not normal to have such a small amount of milk; let me notify your doctor.”
B. “This is colostrum, which is normal and very nutritious for your baby.”
A breastfeeding client develops mastitis and reports flu-like symptoms, a painful breast, and redness in one area. What is the nurse’s best advice?
A. Stop breastfeeding from the affected breast until the symptoms subside.
B. Apply warm compresses and continue breastfeeding frequently.
C. Avoid breastfeeding and pump only from the affected breast.
D. Massage the breast vigorously to reduce inflammation.
B. Apply warm compresses and continue breastfeeding frequently.
A postpartum client suddenly reports chest pain, dyspnea, and a feeling of doom. What is the nurse’s priority intervention?
A. Place the client in a high-Fowler’s position.
B. Assess for signs of thrombophlebitis in the legs.
C. Call for emergency assistance immediately.
D. Administer oxygen via nasal cannula.
C. Call for emergency assistance immediately.
A postpartum client who delivered vaginally 2 hours ago has a saturated perineal pad within 15 minutes. What is the nurse’s priority action?
A. Notify the healthcare provider immediately.
B. Assess the fundus for firmness and location.
C. Encourage the client to ambulate to the bathroom.
D. Start an IV infusion of lactated Ringer’s solution.
B. Assess the fundus for firmness and location.
A nurse is assessing a postpartum client who reports feeling tearful, irritable, and overwhelmed, despite the birth of her healthy infant. These feelings have persisted for the past few days. Which response by the nurse is most appropriate?
A. “This is a normal part of postpartum recovery, and it should resolve on its own in a few weeks.”
B. “You may be experiencing postpartum depression. Let me arrange a referral to a mental health provider.”
C. “These symptoms are common signs of postpartum psychosis. You need immediate psychiatric intervention.”
D. “Your feelings are unusual and may require medication to correct the imbalance.”
A. “This is a normal part of postpartum recovery, and it should resolve on its own in a few weeks.”
Postpartum blues
A breastfeeding mother reports sore, cracked nipples. What is the nurse’s best advice?
A. “Limit the duration of breastfeeding sessions.”
B. “Ensure your baby only latches onto the nipple.”
C. “Stop breastfeeding until the soreness resolves completely.”
D. “Use a lanolin cream or nipple shield to promote healing.”
D. “Use a lanolin cream or nipple shield to promote healing.”
A postpartum nurse is assessing a client’s fundus 24 hours after delivery. Where should the nurse expect to palpate the uterus?
A. At the level of the umbilicus.
B. 1–2 fingerbreadths above the umbilicus.
C. 1–2 fingerbreadths below the umbilicus.
D. Midway between the umbilicus and pubic symphysis.
C. 1–2 fingerbreadths below the umbilicus.
A postpartum client with excessive vaginal bleeding has pale skin, a weak pulse, and a blood pressure of 80/50 mmHg. What is the nurse’s first action?
A. Place the client in Trendelenburg’s position.
B. Administer a prescribed IV fluid bolus.
C. Massage the uterus to promote contraction.
D. Notify the healthcare provider immediately.
C. Massage the uterus to promote contraction.
A nurse is assessing a postpartum client who is exhibiting signs of confusion, agitation, delusions, and hallucinations. What is the nurse’s priority action?
A. Provide the client with information about postpartum blues and reassure her.
B. Administer the prescribed sedative and monitor the client’s behavior.
C. Immediately notify the healthcare provider and ensure the safety of the client and infant.
D. Encourage the client to sleep and avoid stimulating activities.
C. Immediately notify the healthcare provider and ensure the safety of the client and infant.
Postpartum psychosis
A nurse is performing a perineal assessment on a postpartum client who delivered vaginally. Which of the following findings should be reported to the healthcare provider immediately?
A. Swelling and bruising around the perineum
B. A small, non-tender hemorrhoid
C. A 3rd-degree perineal laceration with no signs of infection
D. A large, tender hematoma on the perineum
D. A large, tender hematoma on the perineum
Which condition in a breastfeeding mother is an absolute contraindication to breastfeeding?
A. Mastitis.
B. Maternal HIV infection.
C. Maternal diabetes.
D. Postpartum depression.
B. Maternal HIV infection.
A postpartum client who is Rh-negative has given birth to an Rh-positive baby. When should the nurse administer Rho(D) immune globulin (RhoGAM)?
A. Within 6 hours postpartum.
B. At the 6-week postpartum check-up.
C. Within 72 hours postpartum.
D. At the first prenatal visit during the next pregnancy.
C. Within 72 hours postpartum.
A postpartum client presents with fever, foul-smelling lochia, and uterine tenderness. Which condition should the nurse suspect?
A. Mastitis
B. Endometritis
C. Postpartum depression
D. Thrombophlebitis
B. Endometritis (uterine lining infection)
Which of the following is a hallmark sign of postpartum depression (PPD) that differentiates it from the more transient postpartum blues?
A. Intense feelings of joy and bonding with the baby
B. A sudden onset of mood swings that resolve within 1 week
C. Persistent feelings of sadness, irritability, and lack of interest in the baby
D. Feeling overwhelmed, but able to function normally and care for the baby
C. Persistent feelings of sadness, irritability, and lack of interest in the baby