Davis Edge: Postpartum Physiological Assessments and Nursing Care
When performing a fundal assessment on a patient, 2 hours following an uncomplicated vaginal delivery, the postpartum nurse notes a boggy uterus. What is the priority nursing action for this patient? 1. Massage the fundus with the palm of the hand 2. Place an indwelling catheter 3. Notify the physician or midwife 4. Give Oxytocin as per the physician's orders
1
A nurse is caring for a patient 2 hours post-vaginal delivery of a term neonate. The patient suddenly complains of heavy bleeding, nausea, and dizziness. Vital signs are BP 85/49, HR 110, RR 18, O2 saturation 90%, temp 98.3 F. Based on these assessment findings, what is the priority nursing intervention? 1. Administer oxygen per nasal cannula. 2. Achieve free-flowing venous access. 3. Increase frequency of vital signs. 4. Prepare for emergency dilation and curettage.
1
A postpartum nurse is caring for a G1P1 patient 24 hours post-vaginal delivery. What is the priority action for the nurse when preparing to assess for uterine involution? 1. Assist the woman to a supine. 2. Instruct the woman to void. 3. Reassure the woman that she will not feel pain during the procedure. 4. Notify the woman that you will be visualizing her perineum.
1
A postpartum nurse is caring for a patient 2 hours after vaginal delivery of a large for gestational age (LGA) infant. Assessment findings include moderate lochia rubra, and a firm fundus at the midline and 1 centimeter below the umbilicus. The patient is unable to void. What is the priority nursing action? 1. Encourage fluids and try again in 1 hour 2. Perform an in-and-out catheterization 3. Notify the physician or midwife 4. Use a bladder scanner to assess urine volume
1
A postpartum nurse is caring for a patient immediately following vaginal delivery of a term neonate. The patient reports shortness of breath and a cough, and has the following vital signs: BP 110/73, HR 121, O2 saturation 92%, temp 99.1 F. The nurse recognizes the patient could be experiencing what complication? 1. Pulmonary embolism 2. Postpartum hemorrhage 3. Preeclampsia 4. Pulmonary edema
1
A postpartum nurse is caring for a patient who gave birth 1 hour ago following a 24-hour long induction. The patient had an epidural for pain control during labor. What assessment finding should immediately be reported to the healthcare provider? 1. Boggy uterus 2. Bilateral lower extremity numbness 3. Uncontrollable shaking 4. Moderate vaginal bleeding
1
A postpartum patient asks the nurse if she needs to use contraception while breastfeeding. What is the most therapeutic response by the nurse? 1. "Yes, because breastfeeding is not an effective contraceptive method." 2. "You cannot get pregnant as long as you are breastfeeding." 3. "It takes 9 to 10 weeks for your hormone levels to allow you to get pregnant." 4. "That is a question for your doctor to answer."
1
A postpartum patient reports urinary frequency, urgency, and pain with urination. What is the priority nursing intervention for this patient? 1. Assess the patient's temperature. 2. Instruct the patient to use the peri-bottle when she voids. 3. Assist the patient with a sitz bath. 4. Send a urine specimen for culture and sensitivity.
1
During a routine assessment, the nurse notes diastasis recti abdominis on a postpartum patient. What is the priority nursing intervention for this patient? 1. Continue with the assessment, as this is a normal finding. 2. Notify the physician or midwife STAT. 3. Assist the woman in applying an abdominal binder. 4. Instruct the woman to avoid using her abdominal muscles.
1
Immediately after birth, the nurse notes the patient's fundus is palpated midway between the umbilicus and symphysis pubis. What is the priority nursing action? 1. Document the findings as within normal limits 2. Perform fundal massage 3. Instruct the woman to empty her bladder 4. Reassess every 5 minutes
1
The postpartum nurse is educating a patient who is preparing to go home from the hospital. Which statements made by the patient indicate understanding of contraceptive use after childbirth? 1. "Just because I am breastfeeding does not mean I cannot get pregnant." 2. "I do not need to use condoms until I stop breastfeeding." 3. "I will need to use contraception once I get my period." 4. "Breastfeeding is an effective form of birth control." 5. "I do not need to use contraceptives for the first 6 weeks."
1
The postpartum nurse is preparing to ambulate a patient who received an epidural. What is the priority nursing intervention for this patient? 1. Assess for decreased nerve sensation. 2. Assess for vaginal bleeding. 3. Assess for bladder distension. 4.
1
What statement made by a postpartum patient indicates to the nurse understanding of weight-loss after childbirth? 1. "The average woman is almost back to her pre-pregnancy weight within 6 months." 2. "Most women will experience significant weight loss during the first week postpartum." 3. "I will probably lose 10 pounds as the result of delivery." 4. "I will seat-out 2 to 3 pounds of water weight."
1
he postpartum nurse is caring for a patient who gave birth vaginally 2 hours ago. The nurse notices continued heavy bleeding with firm fundal tone. What nursing action is a priority for this patient? 1. Assess for the presence of a vaginal hematoma 2. Perform vigorous fundal massage 3. Manually extract retained placental fragments 4. Document the findings as within normal limits
1
A patient on the postpartum unit reports passing an egg-sized clot. What are the priority nursing interventions for this patient? Select all that apply. 1. Weigh the clot. 2. Report the findings to the physician or midwife. 3. Assist the patient to the bathroom. 4. Administer Oxytocin 10U IM. 5. Call for rapid response.
1, 2
A nurse is caring for a G2P2 patient in the initial hour after giving birth. What are the appropriate nursing interventions to be taken with this patient? Select all that apply. 1. Assess the uterus for location, position and tone of fundus every 15 minutes 2. Titrate IV Oxytocin infusion rate to uterine tone 3. Provide information regarding afterpains 4. Assess lochia for color, amount, and odor 5. Inspect the inside of the vagina for tearing
1, 2, 3, 4
A postpartum nurse caring for a patient who had a vaginal delivery 3 hours ago notices heavy lochia. What are the priority nursing interventions for this patient? 1. Assess the position, tone and location of the fundus 2. Massage a boggy uterus 3. Document the findings and reassess in 1 hour 4. Quantify blood loss 5. Instruct the client to void and reevaluate
1, 2, 4, 5
A multiparous patient asks the nurse why she is feeling contractions 8 hours after giving birth. What information should the nurse include in her teaching? Select all that apply. 1. "The intensity of the afterpains should decrease in a few days." 2. "The pains are from your abdominal muscles stretching during pregnancy." 3. "You probably don't remember feeling afterpains after your first baby." 4. "The afterpains are more intense because you are not breastfeeding." 5. "Because you had Pitocin during labor, you will feel more contractions after delivery."
1, 3
A nurse is caring for a patient who reports a spinal headache. What statements made by the patient indicate an understanding of a postdural puncture headache? Select all that apply. 1. "I should drink a cola." 2. "My headache will get better when I stand up." 3. "My head hurts because the fluid around my spinal cord is decreased." 4. "Dehydration caused my headache." 5. "I should start to feel better in a few hours."
1, 3
The postpartum nurse is preparing to administer Rh (D) Immune Globulin (RhoGAM) to a post- cesarean section patient on the mother-baby unit. What statements made by the patient indicate an understanding of RhoGAM? Select all that apply. 1. "I need this because my blood type is negative and my baby is positive." 2. "I will avoid pregnancy for 4 weeks." 3. "This medication will help protect my future babies." 4. "I only need to get this once in my lifetime." 5. "I need to receive RhoGAM within 48 hours of giving birth."
1, 3
What information is important for the postpartum nurse to include when educating a patient receiving the Measles, Mumps, and Rubella (MMR) vaccine after childbirth? Select all that apply. 1. "Avoid pregnancy for 4 weeks after receiving the vaccine." 2. "Report a temperature over 99.0 to your physician or midwife." 3. "You are receiving this vaccine because you are not immune to the rubella virus." 4. "You may experience pain, redness, and swelling around the injection site." 5. "You will only need this vaccine once in your lifetime."
1, 3, 4
A nurse is caring for a patient 24 hours post-delivery. What information is important for the postpartum nurse to include in this patient's discharge teaching? Select all that apply. 1. "Rise slowly to a standing position." 2. "You can resume physical activity as soon as you feel up for it." 3. "Drink plenty of water or Gatorade." 4. "You might feel lightheaded when you stand because of the blood you lost during delivery." 5. "Sit down if you feel dizzy or faint."
1, 3, 5
When educating a non-breastfeeding primiparous patient, what information is important for the nurse to include? Select all that apply. 1. "Wear a supportive bra or sports bra 24 hours a day." 2. "If your breasts become engorged, you should pump to relieve the pressure." 3. "Do not apply ice packs to the breasts because it will stimulation milk production." 4. "You can take an analgesic for pain." 5. "You may experience milk leakage for the first 1 to 2 weeks."
1, 4
A G4P4 patient who is 6 hours post-delivery is complaining of severe cramp-like uterine pains. What is a therapeutic nursing response? 1. "The cramping should go away when you start breastfeeding." 2. "The pains are caused by your uterus contracting and should get better in a few days." 3. "Afterpains are usually the worse with your first baby." 4. "The contractions will subside over the next 6 weeks as your uterus goes back to its normal size."
2
A nurse is caring for a patient 24 hours post-cesarean section. Upon assessment, the nurse notes tachycardia, anxiousness, and oxygen saturation of 89%. What is the priority nursing action? 1. Weigh all pads and calculate quantitative blood loss. 2. Apply O2 per nasal cannula. 3. Increase IV fluids. 4. Notify rapid response team.
2
A nurse is caring for a patient 6 hours post-vaginal delivery of a term neonate. She notes a white blood cell count of 20,000/mm. What is the priority nursing intervention for this patient? 1. Notify the physician or midwife 2. Interpret as a normal finding 3. Administer Tylenol 1,000mg PO 4. Order a repeat CBC for the next morning
2
A nurse is caring for a patient in the first hour following a vaginal delivery. What is the priority nursing intervention? 1. Facilitate bonding between the mother and infant 2. Assess the fundus for location, position and tone 3. Administer pain medications 4. Inspect the perineum for tearing
2
A nurse is preparing to administer the Measles, Mumps, and Rubella (MMR) vaccine to a patient before discharge from the hospital. What question is most important for the nurse to ask prior to administering the vaccine? 1. "Do you plan on becoming pregnant again in the next 6 months?" 2. "Did you recently receive the RhoGAM?" 3. "Which arm do you prefer I give this in?" 4. "Have you ever had this vaccine before?"
2
A postpartum nurse caring for a patient 3 days post-delivery notes brown vaginal discharge. How should the nurse document this finding in the electronic health record? 1. Lochia rubra 2. Lochia serosa 3. Lochia alba 4. Brown vaginal discharge
2
A postpartum nurse is caring for a patient 48 hours post-cesarean section. The patient's lab values are: blood type O positive, group B strep positive, rubella non-immune, hepatitis B negative. Based on these assessment findings, what order should be questioned by the nurse? 1. Measles, Mumps, and Rubella (MMR) vaccine Sub Q 2. RhoGAM 300 mcg IM 3. Hydrocodone 7.5/325 mg PO Q4hr PRN 4. Adacel 0.5 ml IM before discharge
2
A postpartum nurse is caring for a patient recovering from vaginal delivery of a term neonate 24 hours ago. The patient had an uncomplicated pregnancy and delivery. What is a priority assessment for this patient? 1. Assess the breasts for signs of mastitis 2. Assess the calf and groin areas for tenderness, edema and warmth 3. Assess the nipples for cracks and bruising 4. Assess the lower extremities for mild swelling
2
A postpartum nurse is caring for multiple patients on the mother-baby unit. Which patient does the nurse assess as being at the highest risk for fluid volume overload? 1. A G1P0 who had an epidural for 6 hours during labor 2. A G3P2 who was induced with Pitocin for preeclampsia 3. A G8P2 with insulin-controlled gestational diabetes 4. A G2P2 who had a repeat cesarean section 24 hours ago
2
A postpartum nurse is caring for multiple patients on the mother-baby unit. Which patient should the nurse evaluate first? 1. A G1P1 who gave birth 30 minutes ago and reports uncontrollable shaking 2. A G6P5 who gave birth 6 hours ago and reports passing a basketball-sized blood clot 3. A G3P1 who is 3 days post-op cesarean section and reports cracked and bloody nipples 4. A G2P1 who is 2 days post-op cesarean section and reports 7/10 abdominal pain
2
A postpartum patient complains of a headache that is worse when in an upright position that improves when supine. What is the priority nursing intervention? 1. Administer Tylenol 650mg PO 2. Notify the anesthesia provider 3. Encourage the patient to lay down and rest 4. Increase IV fluids to promote rehydration
2
A postpartum patient expresses concern that she will get a blood clot in her leg because her mother had one after her delivery. What is the most therapeutic response by the nurse? 1. "Blood clots do not run in families, so you have nothing to worry about." 2. "I understand your concern. Let's take a look at the back of your legs together." 3. "Women are only at risk for developing blood clots during pregnancy." 4. "I will assist you to ambulate around the hallway so that doesn't happen."
2
A primiparous patient tells the nurse she wants to bottle-feed her baby. What is the most therapeutic response by the nurse? 1. "Have you tried breastfeeding? Let's see if we can get baby to latch." 2. "You'll want to wear a sports bra for 24 hours a day until your breasts are soft." 3. "We do not advocate bottle-feeding, so you'll need to bring your own formula." 4. "Are you sure? Breastmilk is so much healthier for your baby."
2
What statement made by a primiparous patient 4 hours post-delivery requires further assessment by the nurse? 1. "Is it normal for it to burn when I go pee?" 2. "My uterus is cramping really bad." 3. "I think I want to try breastfeeding." 4. "Will you take the baby to the nursery so I can nap?"
2
A nurse is educating a patient about deep vein thrombosis (DVT). What information should be included in the discharge plan? Select all that apply. 1. "Hit your call light when you are ready to get out of bed for the first time." 2. "Avoid crossing your legs while sitting." 3. "Your doctor wants you to wear compression stockings." 4. "Make sure not to walk around too much." 5. "Massage your calves daily to prevent a blood clot."
2, 3
Which response by a postpartum patient indicates to the nurse that learning of uterine involution has taken place? Select all that apply. 1. "My uterus will stay this big until I get my period again." 2. "It will take between 6-8 weeks for my uterus to return to normal size." 3. "Contractions will cause my uterus to shrink." 4. "My uterus will not be as small as it was before I had a baby." 5. "My uterus will return to the size of a volleyball."
2, 3
A postpartum client asks the nurse why her temperature is slightly elevated. What is the correct response from the nurse? Select all that apply. 1. "You had a fever during labor and the antibiotics have not started working yet." 2. "The hard work of labor can cause your temperature to increase." 3. "It is common for women to experience mild temperature elevation after giving birth." 4. "Your body is going through a lot of hormonal changes right now, which can increase your temperature." 5. "Do you feel hot? I will get you some Tylenol."
2, 3, 4
A nurse is caring for a patient in the immediate postpartum period. Upon assessment, the nurse notes heavy bleeding and a boggy uterus that does not respond to fundal massage. What are the priority nursing actions? Place in the correct order. 1 Increase frequency of vital signs 2 Perform fundal massage 3 Notify the physician or midwife of excessive blood loss 4 Achieve free-flowing venous access
2, 3, 4, 1
The postpartum nurse is educating a patient about what to expect when she goes home. What information about diaphoresis is important to include in the teaching? Select all that apply. 1. "Sweating occurs in the weeks after childbirth because of increased estrogen levels." 2. "You might experience periods of profuse sweating." 3. "This is your body's way of getting rid of extra fluid." 4. "Wearing a cotton nightgown will help with comfort." 5. "If you experience profuse sweating you should take your temperature."
2, 3, 4, 5
A nurse is caring for a postpartum patient who gave birth to her first baby 24 hours ago. What actions should the nurse perform to help promote rest and sleep? Select all that apply. 1. Administer Zolpidem 5mg PO. 2. Cluster nursing care, such as assessments and interventions. 3. Encourage woman to sleep when the baby sleeps. 4. Suggest a postpartum nanny. 5. Medicate for pain as per orders.
2, 3, 5
A postpartum patient is preparing to administer Colace to a patient who gave birth 12 hours ago. What information is important for the nurse to understand regarding gastrointestinal (GI) function post-birth? Select all that apply. 1. Gastrointestinal muscle tone increases post-birth. 2. Gastrointestinal motility decreases post-birth. 3. The risk for constipation decreases post-birth. 4. Gastrointestinal function returns to normal within two weeks. 5. Hemorrhoids are not common during pregnancy and birth.
2, 4
The postpartum nurse is educating a patient on bowel function post-childbirth. What information is important for the nurse to include? Select all that apply. 1. "Drink at least 2 liters of fluids a day." 2. "Eat a lot of fruits and vegetables." 3. "Avoid whole grains and legumes." 4. "Your bowels should be back to normal within 2-3 days." 5. "Try not to ambulate too much."
2, 4
What statement made by a postpartum patient indicates to the nurse understanding of discharge instructions? 1. "I do not need to schedule a follow-up doctor appointment if I am not experiencing complications." 2. "I will notify my midwife if my breasts get engorged." 3. "I will call my doctor if I experience heavy lochia." 4. "I will see my doctor again in 2 weeks for a follow-up appointment." Rationales
3
A G6P5 patient who is 24-hours post vaginal delivery reports severe cramp-like uterine pain. What is the priority nursing intervention for this patient? 1. Document the pain score in the electronic medical record. 2. Assess the perineum for a vaginal hematoma. 3. Encourage warm packs to the abdomen. 4. Notify the healthcare provider STAT.
3
A nurse is caring for a patient who gave birth 30 minutes ago. Upon fundal assessment, the nurse notes moderate vaginal bleeding and a boggy uterus that does not respond to fundal massage. What is the priority nursing action? 1. Continue fundal massage. 2. Document the findings and reassess in 5 to 10 minutes. 3. Increase IV Oxytocin rate. 4. Administer misoprostol 600mg rectally.
3
A postpartum nurse is caring for multiple patients on the mother-baby unit. Which task can the nurse delegate to the Licensed Practical Nurse (LPN)? 1. Re-admit a patient 2 weeks post-op cesarean section with an infection 2. A G1P1 needing discharge teaching 3. A G2P1 who gave birth yesterday and has moderate lochia rubra 4. A G6P6 2 days post-op cesarean section at 34 weeks gestation
3
A postpartum patient asks the nurse when she can expect to get her period again. What is the correct response by the nurse? 1. "Your period will return when you stop breastfeeding." 2. "Because you are breastfeeding, you can expect to get your period 7-9 weeks post-birth." 3. "Return of your period depends on how long and how much you breastfeed." 4. "Most women get their period within 10 weeks of delivery."
3
The postpartum nurse is educating a patient who is receiving the Measles, Mumps, and Rubella (MMR) vaccine. What statement made by the patient indicates the need for further teaching? 1. "My arm might be sore where I was given a shot." 2. "I will avoid pregnancy for 4 weeks." 3. "I will need to receive this vaccine again during my next pregnancy." 4. "I am being vaccinated against German measles."
3
A nurse is educating a patient on the mother-baby unit about breastfeeding. Which statements made by the patient indicate need for further teaching? Select all that apply. 1. "During the first 24 hours postpartum, my breasts should be soft and non-tender." 2. "Colostrum gives my baby protection from viruses and bacteria." 3. "Colostrum is thick and whitish in color." 4. "Colostrum has more carbohydrates than breast milk." 5. "I might feel throbbing pain in my breasts for the first 1 to 2 days."
3, 4
A perinatal nurse is educating a patient with preeclampsia about potential complications during delivery. What important information should the nurse include in the teaching? 1. "Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 2 weeks postpartum." 2. "Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 6 weeks postpartum." 3. "Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 6 months postpartum." 4. "Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 1 year postpartum."
4
During routine assessment, a nurse caring for a postpartum patient notes the uterus is shifted to the side. What is the priority nursing action? 1. Notify the physician or midwife. 2. Document the findings in the electronic medical record. 3. Perform gentle fundal massage. 4. Assist the woman to the bathroom.
4