NR327 - Quiz 4 - Postpartum NCLEX-Style Questions (For Quiz 4) Postpartum Physiological/Psychosocial Adaptations & Postpartum Complications NCLEX-Style Questions (For Quiz 4):
1. A nurse is performing a fundal assessment for a client who is 2 days postpartum and observes the perineal pad for loc...
1. A nurse is performing a fundal assessment for a client who is 2 days postpartum and observes
the perineal pad for lochia. she notes the pad to be saturated approximately 12 cm with lochia
that is bright red and contains small clots. Which of the following findings should the nurse
document?
A. Moderate lochia rubra
B. Excessive blood loss
C. Light lochia rubra
D. Scant lochia serosa
Rationale:
A. CORRECT: The client has moderate lochia rubra containing small clots, which is an
expected finding for the second day postpartum.
B. Excessive blood loss is saturation of a perineal pad in 15 min or less or pooling of blood
under the client's buttocks.
C. Light lochia rubra is a perineal pad that is saturated less than 10 cm with lochia.
D. Scant lochia serosa (less than 2.5 cm on perineal pad) is pinkish brown in color and
serosanguineous in consistency. it occurs on day 4 to 12 following delivery."
2. During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood
that soon stops. on assessment, a nurse finds the uterus to be firm, midline, and at the level of the
, umbilicus. Which of the following findings should the nurse interpret this data as being?
a. Evidence of a possible vaginal hematoma B. an indication of a cervical or perineal laceration
c. a normal postural discharge of lochia d. abnormally excessive lochia rubra flow
Rationale:
A. A client who has a vaginal hematoma is expected to report excessive pain or vaginal pressure.
B. Excessive spurting of bright red blood from the vagina indicates a possible cervical or
perineal laceration.
C. CORRECT: lochia typically trickles from the vaginal opening but flows more steadily during
uterine contractions. massaging the uterus or ambulation can result in a gush of lochia with the
expression of clots and dark blood that has been pooled in the vagina, but it should soon decrease
back to a trickle of bright red lochia in the early puerperium.
D. Excessive blood loss consists of one pad saturated in 15 min or less or the pooling of blood
under the buttocks, which is not affected by the client's postural changes."
3. A nurse is completing postpartum discharge teaching to a client who had no immunity to
varicella and was given varicella vaccine. Which of the following statements by the client
indicates understanding of the teaching?
A. "i will need to use contraception for 3 months before considering pregnancy."
B. "i need a second vaccination at my postpartum visit."
C. "i was given the vaccine because my baby is o-positive."
D. "i will be tested in 3 months to see if i have developed immunity."
Rationale:
A. A client is instructed to not get pregnant for 1 month following administration of varicella
vaccine.
B. CORRECT: A second varicella immunization is needed at 4 to 8 weeks following delivery
by clients who had no history of immunity.
C. Rho(d) immune globulin is administered to a Rh-Negative mother who has an rh-positive
newborn.
D. A client requires testing for immunity at 3 months following administration of rubella
vaccine and rho(d) immune globulin."
4. a nurse is assessing a postpartum client for fundal height, location, and consistency. the fundus
is noted to be displaced laterally to the right, and there is uterine atony. the nurse should identify
which of the following conditions as the cause of the uterine atony? a. Poor involution B. urinary
retention c. hemorrhage d. infection
Rationale:
B "a. Poor involution is the result of uterine atony and does not cause it. B. CORRECT: urinary
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