NCLEX OBSTETRICS PRACTICE EXAM

1. A postpartum nurse is preparing to care for a woman who has just delivered a healthy newborn
infant. In the immediate postpartum period the nurse plans to take the woman's vital signs:

a. Every 30 minutes during the first hour and then every hour for the next two hours.
b. Every 15 minutes during the first hour and then every 30 minutes for the next two hours.
c. Every hour for the first 2 hours and then every 4 hours
d. Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours.

2. A postpartum nurse is taking the vital signs of a woman who delivered a healthy newborn
infant 4 hours ago. The nurse notes that the mother's temperature is 100.2*F. Which of the
following actions would be most appropriate?

a. Retake the temperature in 15 minutes

b. Notify the physician
c. Document the findings
d. Increase hydration by encouraging oral fluids

3. The nurse is assessing a client who is 6 hours PP after delivering a full-term healthy infant.
The client complains to the nurse of feelings of faintness and dizziness. Which of the following
nursing actions would be most appropriate?

a. Obtain hemoglobin and hematocrit levels

b. Instruct the mother to request help when getting out of bed
c. Elevate the mother's legs
d. Inform the nursery room nurse to avoid bringing the newborn infant to the mother until
the feelings of light-headedness and dizziness have subsided.

4. A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing
action in performing this assessment is which of the following?

a. Ask the client to turn on her side

b. Ask the client to lie flat on her back with the knees and legs flat and straight.
c. Ask the mother to urinate and empty her bladder
d. Massage the fundus gently before determining the level of the fundus.

5. The nurse is assessing the lochia on a 1 day PP patient. The nurse notes that the lochia is red
and has a foul-smelling odor. The nurse determines that this assessment finding is:

a. Normal
 b. Indicates the presence of infection
c. Indicates the need for increasing oral fluids
d. Indicates the need for increasing ambulation

6. When performing a PP assessment on a client, the nurse notes the presence of clots in the
lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which of the
following nursing actions is most appropriate?

a. Document the findings

b. Notify the physician
c. Reassess the client in 2 hours
d. Encourage increased intake of fluids.

7. A nurse in a PP unit is instructing a mother regarding lochia and the amount of expected
lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but
should never exceed the need for:

a. One peripad per day

b. Two peripads per day
c. Three peripads per day
d. Eight peripads per day

8. A PP nurse is providing instructions to a woman after delivery of a healthy newborn infant.

The nurse instructs the mother that she should expect normal bowel elimination to return:

a. On the day of the delivery

b. 3 days PP
c. 7 days PP
d. within 2 weeks PP

9. Select all of the physiological maternal changes that occur during the PP period.

a. Cervical involution ceases immediately

b. Vaginal distention decreases slowly
c. Fundus begins to descend into the pelvis after 24 hours
d. Cardiac output decreases with resultant tachycardia in the first 24 hours
e. Digestive processes slow immediately.

10. A nurse is caring for a PP woman who has received epidural anesthesia and is monitoring the
woman for the presence of a vulva hematoma. Which of the following assessment findings
would best indicate the presence of a hematoma?
 a. Complaints of a tearing sensation
b. Complaints of intense pain
c. Changes in vital signs
d. Signs of heavy bruising

11. A nurse is developing a plan of care for a PP woman with a small vulvar hematoma. The
nurse includes which specific intervention in the plan during the first 12 hours following the
delivery of this client?

a. Assess vital signs every 4 hours

b. Inform health care provider of assessment findings
c. Measure fundal height every 4 hours
d. Prepare an ice pack for application to the area.

12. A new mother received epidural anesthesia during labor and had a forceps delivery after
pushing 2 hours. At 6 hours PP, her systolic blood pressure has dropped 20 points, her diastolic
BP has dropped 10 points, and her pulse is 120 beats per minute. The client is anxious and
restless. On further assessment, a vulvar hematoma is verified. After notifying the health care
provider, the nurse immediately plans to:

a. Monitor fundal height

b. Apply perineal pressure
c. Prepare the client for surgery.
d. Reassure the client

13. A nurse is monitoring a new mother in the PP period for signs of hemorrhage. Which of the
following signs, if noted in the mother, would be an early sign of excessive blood loss?

a. A temperature of 100.4*F
b. An increase in the pulse from 88 to 102 BPM
c. An increase in the respiratory rate from 18 to 22 breaths per minute
d. A blood pressure change from 130/88 to 124/80 mm Hg

14. A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum
period. When the nurse locates the fundus, she notes that the uterus feels soft and boggy. Which
of the following nursing interventions would be most appropriate initially?

a. Massage the fundus until it is firm

b. Elevate the mothers legs
c. Push on the uterus to assist in expressing clots
 d. Encourage the mother to void

15. A PP nurse is assessing a mother who delivered a healthy newborn infant by C-section. The
nurse is assessing for signs and symptoms of superficial venous thrombosis. Which of the
following signs or symptoms would the nurse note if superficial venous thrombosis were
present?

a. Paleness of the calf area

b. Enlarged, hardened veins
c. Coolness of the calf area
d. Palpable dorsalis pedis pulses

16. A nurse is providing instructions to a mother who has been diagnosed with mastitis. Which
of the following statements if made by the mother indicates a need for further teaching?

a. "I need to take antibiotics, and I should begin to feel better in 24-48 hours."
b. "I can use analgesics to assist in alleviating some of the discomfort."
c. "I need to wear a supportive bra to relieve the discomfort."
d. "I need to stop breastfeeding until this condition resolves."

17. A PP client is being treated for DVT. The nurse understands that the client's response to
treatment will be evaluated by regularly assessing the client for:

a. Dysuria, ecchymosis, and vertigo

b. Epistaxis, hematuria, and dysuria
c. Hematuria, ecchymosis, and epistaxis
d. Hematuria, ecchymosis, and vertigo

18. A nurse performs an assessment on a client who is 4 hours PP. The nurse notes that the client
has cool, clammy skin and is restless and excessively thirsty. The nurse prepares immediately to:

a. Assess for hypovolemia and notify the health care provider

b. Begin hourly pad counts and reassure the client
c. Begin fundal massage and start oxygen by mask
d. Elevate the head of the bed and assess vital signs

19. A nurse is assessing a client in the 4th stage if labor and notes that the fundus is firm but that
bleeding is excessive. The initial nursing action would be which of the following?

a. Massage the fundus

b. Place the mother in the Trendelenburg's position
 c. Notify the physician
d. Record the findings

20. A nurse is caring for a PP client with a diagnosis of DVT who is receiving a continuous
intravenous infusion of heparin sodium. Which of the following laboratory results will the nurse
specifically review to determine if an effective and appropriate dose of the heparin is being
delivered?

a. Prothrombin time
b. Internationalized normalized ratio
c. Activated partial thromboplastin time
d. Platelet count

21. A nurse is preparing a list of self-care instructions for a PP client who was diagnosed with
mastitis. Select all instructions that would be included on the list.

a. Take the prescribed antibiotics until the soreness subsides.

b. Wear supportive bra
c. Avoid decompression of the breasts by breastfeeding or breast pump
d. Rest during the acute phase
e. Continue to breastfeed if the breasts are not too sore.

22. Methergine or pitocin is prescribed for a woman to treat PP hemorrhage. Before

administration of these medications, the priority nursing assessment is to check the:

a. Amount of lochia
b. Blood pressure
c. Deep tendon reflexes
d. Uterine tone

23. Methergine or pitocin are prescribed for a client with PP hemorrhage. Before administering
the medication(s), the nurse contacts the health provider who prescribed the medication(s) in
which of the following conditions is documented in the client's medical history?

a. Peripheral vascular disease

b. Hypothyroidism
c. Hypotension
d. Type 1 diabetes

24. Which of the following factors might result in a decreased supply of breast milk in a PP
mother?
 a. Supplemental feedings with formula
b. Maternal diet high in vitamin C
c. An alcoholic drink
d. Frequent feedings

25. Which of the following interventions would be helpful to a breastfeeding mother who is
experiencing engorged breasts?

a. Applying ice
b. Applying a breast binder
c. Teaching how to express her breasts in a warm shower
d. Administering bromocriptine (Parlodel)

26. On completing a fundal assessment, the nurse notes the fundus is situated on the client's left
abdomen. Which of the following actions is appropriate?

a. Ask the client to empty her bladder

b. Straight catheterize the client immediately
c. Call the client's health provider for direction
d. Straight catheterize the client for half of her uterine volume

27. The nurse is about the give a Type 2 diabetic her insulin before breakfast on her first day
postpartum. Which of the following answers best describes insulin requirements immediately
postpartum?

a. Lower than during her pregnancy

b. Higher than during her pregnancy
c. Lower than before she became pregnant
d. Higher than before she became pregnant

28. Which of the following findings would be expected when assessing the postpartum client?

a. Fundus 1 cm above the umbilicus 1 hour postpartum

b. Fundus 1 cm above the umbilicus on postpartum day 3
c. Fundus palpable in the abdomen at 2 weeks postpartum
d. Fundus slightly to the right; 2 cm above umbilicus on postpartum day 2

29. A client is complaining of painful contractions, or afterpains, on postpartum day 2. Which of

the following conditions could increase the severity of afterpains?
 a. Bottle-feeding
b. Diabetes
c. Multiple gestation
d. Primiparity

30. On which of the postpartum days can the client expect lochia serosa?

a. Days 3 and 4 PP
b. Days 3 to 10 PP
c. Days 10-14 PP
d. Days 14 to 42 PP

31. Which of the following behaviors characterizes the PP mother in the taking in phase?

a. Passive and dependant

b. Striving for independence and autonomy
c. Curious and interested in care of the baby
d. Exhibiting maximum readiness for new learning

32. Which of the following complications may be indicated by continuous seepage of blood from
the vagina of a PP client, when palpation of the uterus reveals a firm uterus 1 cm below the
umbilicus?

a. Retained placental fragments

b. Urinary tract infection
c. Cervical laceration
d. Uterine atony

33. What type of milk is present in the breasts 7 to 10 days PP?

a. Colostrum
b. Hind milk
c. Mature milk
d. Transitional milk

34. Which of the following complications is most likely responsible for a delayed postpartum
hemorrhage?

a. Cervical laceration
b. Clotting deficiency
c. Perineal laceration
 d. Uterine subinvolution

35. Before giving a PP client the rubella vaccine, which of the following facts should the nurse
include in client teaching?

a. The vaccine is safe in clients with egg allergies

b. Breast-feeding isn't compatible with the vaccine
c. Transient arthralgia and rash are common adverse effects
d. The client should avoid getting pregnant for 3 months after the vaccine because the
vaccine has teratogenic effects

36. Which of the following changes best described the insulin needs of a client with type 1
diabetes who has just delivered an infant vaginally without complications?

a. Increase
b. Decrease
c. Remain the same as before pregnancy
d. Remain the same as during pregnancy

37. Which of the following responses is most appropriate for a mother with diabetes who wants
to breastfeed her infant but is concerned about the effects of breastfeeding on her health?

a. Mothers with diabetes who breast-feed have a hard time controlling their insulin needs
b. Mothers with diabetes shouldn't breastfeed because of potential complications
c. Mothers with diabetes shouldn't breastfeed; insulin requirements are doubled.
d. Mothers with diabetes may breastfeed; insulin requirements may decrease from
breastfeeding.

38. On the first PP night, a client requests that her baby be sent back to the nursery so she can get
some sleep. The client is most likely in which of the following phases?

a. Depression phase
b. Letting-go phase
c. Taking-hold phase
d. Taking-in phase

39. Which of the following physiological responses is considered normal in the early postpartum
period?

a. Urinary urgency and dysuria

b. Rapid diuresis
 c. Decrease in blood pressure
d. Increase motility of the GI system

40. During the 3rd PP day, which of the following observations about the client would the nurse
be most likely to make?

a. The client appears interested in learning about neonatal care

b. The client talks a lot about her birth experience
c. The client sleeps whenever the neonate isn't present
d. The client requests help in choosing a name for the neonate.

41. Which of the following circumstances is most likely to cause uterine atony and lead to PP
hemorrhage?

a. Hypertension
b. Cervical and vaginal tears
c. Urine retention
d. Endometritis

42. Which type of lochia should the nurse expect to find in a client 2 days PP?

a. Foul-smelling
b. Lochia serosa
c. Lochia alba
d. Lochia rubra

43. After expulsion of the placenta in a client who has six living children, an infusion of lactated
ringer's solution with 10 units of pitocin is ordered. The nurse understands that this is indicated
for this client because:

a. She had a precipitate birth

b. This was an extramural birth
c. Retained placental fragments must be expelled
d. Multigravida's are at increased risk for uterine atony.

44. As part of the postpartum assessment, the nurse examines the breasts of a primiparous
breastfeeding woman who is one day postpartum. An expected finding would be:

a. Soft, non-tender; colostrum is present

b. Leakage of milk at let down
c. Swollen, warm, and tender upon palpation
 d. A few blisters and a bruise on each areola

45. Following the birth of her baby, a woman expresses concern about the weight she gained
during pregnancy & how quickly she can lose it now that the baby is born. The nurse, in
describing the expected pattern of weight loss, shld begin by telling her that:

a. Return to prepregnant weight is usually achieved by the end of the postpartum period
b. Fluid loss from diuresis, diaphoresis, and bleeding accounts for about a 3 pound weight
loss
c. The expected weight loss immediately after birth averages about 11 to 13 pounds
d. Lactation will inhibit weight loss since caloric intake must increase to support milk
production

46. Which of the following findings would be a source of concern if noted during the assessment
of a woman who is 12 hours postpartum?

a. Postural hypotension
b. Temperature of 100.4°F
c. Bradycardia — pulse rate of 55 BPM
d. Pain in left calf with dorsiflexion of left foot

47. The nurse examines a woman one hour after birth. The woman's fundus is boggy, midline,
and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The
nurse's initial action would be to:

a. Place her on a bedpan to empty her bladder

b. Massage her fundus
c. Call the physician
d. Administer Methergine 0.2 mg IM which has been ordered prn

48. When performing a postpartum check, the nurse should:

a. Assist the woman into a lateral position with upper leg flexed forward to facilitate the
examination of her perineum
b. Assist the woman into a supine position with her arms above her head and her legs
extended for the examination of her abdomen
c. Instruct the woman to avoid urinating just before the examination since a full bladder will
facilitate fundal palpation
d. Wash hands and put on sterile gloves before beginning the check
49. Perineal care is an important infection control measure. When evaluating a postpartum
woman's perineal care technique, the nurse would recognize the need for further instruction if the
woman:

a. Uses soap and warm water to wash the vulva and perineum
b. Washes from symphysis pubis back to episiotomy
c. Changes her perineal pad every 2 - 3 hours
d. Uses the peribottle to rinse upward into her vagina

50. Which measure would be least effective in preventing postpartum hemorrhage?

a. Administer Methergine 0.2 mg every 6 hours for 4 doses as ordered

b. Encourage the woman to void every 2 hours
c. Massage the fundus every hour for the first 24 hours following birth
d. Teach the woman the importance of rest and nutrition to enhance healing

51. When making a visit to the home of a postpartum woman one week after birth, the nurse
should recognize that the woman would characteristically:

a. Express a strong need to review events and her behavior during the process of labor and
birth
b. Exhibit a reduced attention span, limiting readiness to learn
c. Vacillate between the desire to have her own nurturing needs met and the need to take
charge of her own care and that of her newborn
d. Have re-established her role as a spouse/partner

52. Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby,
stating that she is too tired and just wants to sleep. The nurse should:

a. Tell the woman she can rest after she feeds her baby
b. Recognize this as a behavior of the taking-hold stage
c. Record the behavior as ineffective maternal-newborn attachment
d. Take the baby back to the nursery, reassuring the woman that her rest is a priority at this
time

53. Parents can facilitate the adjustment of their other children to a new baby by:

a. Having the children choose or make a gift to give to the new baby upon its arrival home
b. Emphasizing activities that keep the new baby and other children together
c. Having the mother carry the new baby into the home so she can show the other children
the new baby
 d. Reducing stress on other children by limiting their involvement in the care of the new
baby

54. A primiparous woman is in the taking-in stage of psychosocial recovery and adjustment
following birth. The nurse, recognizing the needs of women during this stage, should:

a. Foster an active role in the baby's care

b. Provide time for the mother to reflect on the events of and her behavior during childbirth
c. Recognize the woman's limited attention span by giving her written materials to read
when she gets home rather than doing a teaching session now
d. Promote maternal independence by encouraging her to meet her own hygiene and
comfort needs

ANSWERS AND RATIONALE

1. B. Every 15 minutes during the first hour and then every 30 minutes for the next two hours.

2. D. The most appropriate action is to increase hydration by encouraging oral fluids, which should bring
the temperature to a normal reading. Although the nurse would document the findings, the most
appropriate action would be to increase the hydration.The mother's temperature may be taken every 4
hours while she is awake. Temperatures up to 100.4 (38 C) in the first 24 hours after birth are often
related to the dehydrating effects of labor.

3. B. Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or
dizziness are signs that should caution the nurse to be aware of the client's safety. The nurse should advise
the mother to get help the first few times the mother gets out of bed. Obtaining an H/H requires a
physician’s order.

4. C. Before starting the fundal assessment, the nurse should ask the mother to empty her bladder so that
an accurate assessment can be done. When the nurse is performing a fundal assessment, the nurse asks the
woman to lie flat on her back with the knees flexed. Massaging the fundus is not appropriate unless the
fundus is boggy and soft, and then it should be massaged gently until firm.

5. B. Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in
amount. Normal lochia has a fleshy odor. Foul smelling or purulent lochia usually indicates infection, and
these findings are not normal. Encouraging the woman to drink fluids or increase ambulation is not an
accurate nursing intervention.

6. B. Normally, one may find a few small clots in the first 1 to 2 days after birth from pooling of blood in
the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine
atony or retained placental fragments, needs to be determined and treated to prevent further blood loss.
Although the findings would be documented, the most appropriate action is to notify the physician.

7. D. The normal amount of lochia may vary with the individual but should never exceed 6 to 8 peripads
per day. The average number of peripads is 6 per day

8. B. After birth, the nurse should auscultate the woman's abdomen in all four quadrants to determine the
return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days PP. Surgery, anesthesia,
and the use of narcotics and pain control agents also contribute to the longer period of altered bowel
function.

9. A and C. In the PP period, cervical healing occurs rapidly and cervical involution occurs. After 1 week
the muscle begins to regenerate and the cervix feels firm and the external os is the width of a pencil.
Although the vaginal mucosa heals and vaginal distention decreases, it takes the entire PP period for
complete involution to occur and muscle tone is never restored to the pregravid state. The fundus begins
to descent into the pelvic cavity after 24 hours, a process known as involution. Despite blood loss that
occurs during delivery of the baby, a transient increase in cardiac output occurs. The increase in cardiac
output, which persists about 48 hours after childbirth, is probably caused by an increase in stroke volume
because Bradycardia is often noted during the PP period. Soon after childbirth, digestion begins to begin
to be active and the new mother is usually hungry because of the energy expended during labor.

10. C. Because the woman has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure,
or a tearing sensation. Changes in vitals indicate hypovolemia in the anesthetized PP woman with vulvar
hematoma. Heavy bruising may be visualized, but vital sign changes indicate hematoma caused by blood
collection in the perineal tissues.

11. D. Application of ice will reduce swelling caused by hematoma formation in the vulvar area. The
other options are not interventions that are specific to the plan of care for a client with a small vulvar
hematoma.
12. C. The use of an epidural, prolonged second stage labor and forceps delivery are predisposing factors
for hematoma formation, and a collection of up to 500 ml of blood can occur in the vaginal area.
Although the other options may be implemented, the immediate action would be to prepare the client for
surgery to stop the bleeding.

13. B. During the 4th stage of labor, the maternal blood pressure, pulse, and respiration should be checked
every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss because the
heart pumps faster to compensate for reduced blood volume. The blood pressure will fall as the blood
volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. A slight
rise in temperature is normal. The respiratory rate is increased slightly.

14. A. If the uterus is not contracted firmly, the first intervention is to massage the fundus until it is firm
and to express clots that may have accumulated in the uterus. Pushing on an uncontracted uterus can
invert the uterus and cause massive hemorrhage. Elevating the client's legs and encouraging the client to
void will not assist in managing uterine atony. If the uterus does not remain contracted as a result of the
uterine massage, the problem may be distended bladder and the nurse should assist the mother to urinate,
but this would not be the initial action.

15. B. Thrombosis of the superficial veins is usually accompanied by signs and symptoms of
inflammation. These include swelling of the involved extremity and redness, tenderness, and warmth.

16. D. In most cases, the mother can continue to breast feed with both breasts. If the affected breast is too
sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent
abscess formation. Antibiotic therapy assists in resolving the mastitis within 24-48 hours. Additional
supportive measures include ice packs, breast supports, and analgesics.

17. C. The treatment for DVT is anticoagulant therapy. The nurse assesses for bleeding, which is an
adverse effect of anticoagulants. This includes hematuria, ecchymosis, and epistaxis. Dysuria and vertigo
are not associated specifically with bleeding.

18. A. Symptoms of hypovolemia include cool, clammy, pale skin, sensations of anxiety or impending
doom, restlessness, and thirst. When these symptoms are present, the nurse should further assess for
hypovolemia and notify the health care provider.

19. C. If the bleeding is excessive, the cause may be laceration of the cervix or birth canal. Massaging the
fundus if it is firm will not assist in controlling the bleeding. Trendelenburg's position is to be avoided
because it may interfere with cardiac function.

20. C. Anticoagulation therapy may be used to prevent the extension of thrombus by delaying the clotting
time of the blood. Activated partial thromboplastin time should be monitored, and a heparin dose should
be adjusted to maintain a therapeutic level of 1.5 to 2.5 times the control. The prothrombin time and the
INR are used to monitor coagulation time when warfarin (Coumadin) is used.
21. B, D and E. Mastitis are an infection of the lactating breast. Client instructions include resting during
the acute phase, maintaining a fluid intake of at least 3L/ day, and taking analgesics to relieve discomfort.
Antibiotics may be prescribed and are taken until the complete prescribed course is finished. They are not
stopped when the soreness subsides. Additional supportive measures include the use of moist heat or ice
packs and wearing a supportive bra. Continued decompression of the breast by breastfeeding or pumping
is important to empty the breast and prevent formation of an abscess.

22. B. Methergine and pitocin are agents that are used to prevent or control postpartum hemorrhage by
contracting the uterus. They cause continuous uterine contractions and may elevate blood pressure. A
priority nursing intervention is to check blood pressure. The physician should be notified if hypertension
is present.

23. A. These medications are avoided in clients with significant cardiovascular disease, peripheral
disease, hypertension, eclampsia, or preeclampsia. These conditions are worsened by the vasoconstriction
effects of these medications.

24. A. Routine formula supplementation may interfere with establishing an adequate milk volume
because decreased stimulation to the mother's nipples affects hormonal levels and milk production.

25. C. Teaching the client how to express her breasts in a warm shower aids with let-down and will give
temporary relief. Ice can promote comfort by vasoconstriction, numbing, and discouraging further
letdown of milk.

26. A. A full bladder may displace the uterine fundus to the left or right side of the abdomen.
Catheterization is unnecessary invasive if the woman can void on her own.

27. C. PP insulin requirements are usually significantly lower than pre-pregnancy requirements.
Occasionally, clients may require little to no insulin during the first 24 to 48 hours postpartum.

28. A. Within the first 12 hours postpartum, the fundus usually is approximately 1 cm above the
umbilicus. The fundus should be below the umbilicus by PP day 3. The fundus shouldn't be palpated in
the abdomen after day 10.

29. C. Multiple gestation, breastfeeding, multiparity, and conditions that cause overdistention of the
uterus will increase the intensity of after-pains. Bottle Feeding and diabetes aren't directly associated with
increasing severity of afterpains unless the client has delivered a macrosomic infant.

30. B. On the third and fourth PP days, the lochia becomes a pale pink or brown and contains old blood,
serum, leukocytes, and tissue debris. This type of lochia usually lasts until PP day 10. Lochia rubra
usually last for the first 3 to 4 days PP. Lochia alba, which contain leukocytes, decidua, epithelial cells,
mucus, and bacteria, may continue for 2 to 6 weeks PP.

31. A. During the taking in phase, which usually lasts 1-3 days, the mother is passive and dependent and
expresses her own needs rather than the neonate's needs. The taking hold phase usually lasts from days 3-
10 PP. During this stage, the mother strives for independence and autonomy; she also becomes curious
and interested in the care of the baby and is most ready to learn.

32. C. Continuous seepage of blood may be due to cervical or vaginal lacerations if the uterus is firm and
contracting. Retained placental fragments and uterine atony may cause subinvolution of the uterus,
making it soft, boggy, and larger than expected. UTI won't cause vaginal bleeding, although hematuria
may be present.

33. D. Transitional milk comes after colostrum and usually lasts until 2 weeks PP

34. D. Late postpartum bleeding is often the result of subinvolution of the uterus. Retained products of
conception or infection often cause subinvolution. Cervical or perineal lacerations can cause an
immediate postpartum hemorrhage. A client with a clotting deficiency may also have an immediate PP
hemorrhage if the deficiency isn't corrected at the time of delivery.

35. D. The client must understand that she must not become pregnant for 3 months after the vaccination
because of its potential teratogenic effects. The rubella vaccine is made from duck eggs so an allergic
reaction may occur in clients with egg allergies. The virus is not transmitted into the breast milk, so
clients may continue to breastfeed after the vaccination. Transient arthralgia and rash are common
adverse effects of the vaccine.

36. A. The placenta produces the hormone human placental lactogen, an insulin antagonist. After birth,
the placenta, the major source of insulin resistance, is gone. Insulin needs decrease and women with type
1 diabetes may only need onehalf to two-thirds of the prenatal insulin during the first few PP days.

37. D. Breastfeeding has an antidiabetogenic effect. Insulin needs are decreased because carbohydrates
are used in milk production. Breastfeeding mothers are at a higher risk of hypoglycemia in the first PP
days after birth because the glucose levels are lower. Mothers with diabetes should be encouraged to
breastfeed.

38. D. The taking-in phase occurs in the first 24 hours after birth. The mother is concerned with her own
needs and requires support from staff and relatives. The taking-hold phase occurs when the mother is
ready to take responsibility for her care as well as the infants care. The letting-go phase begins several
weeks later, when the mother incorporates the new infant into the family unit.

39. B. In the early PP period, there's an increase in the glomerular filtration rate and a drop in the
progesterone levels, which result in rapid diuresis. There should be no urinary urgency, though a woman
may feel anxious about voiding. There's a minimal change in blood pressure following childbirth, and a
residual decrease in GI motility.

40. A. The third to tenth days of PP care are the "taking-hold" phase, in which the new mother strives for
independence and is eager for her neonate. The other options describe the phase in which the mother
relives her birth experience.
41. C. Urine retention causes a distended bladder to displace the uterus above the umbilicus and to the
side, which prevents the uterus from contracting. The uterus needs to remain contracted if bleeding is to
stay within normal limits. Cervical and vaginal tears can cause PP hemorrhage but are less common
occurrences in the PP period.

42. D. Lochia rubra. Lochia rubra lasts 3 to 4 days PP; Lochia serosa begins 3 days PP and lasts 10 days;
Lochia alba begins 2 wks PP and lasts up to 6 weeks. Foul Smelling lochia is an abnormal finding and
indicates an infection.

43. D. Multiple full-term pregnancies and deliveries result in overstretched uterine muscles that do not
contract efficiently and bleeding may ensue.

44. A. Breasts are essentially unchanged for the first two to three days after birth. Colostrum is present
and may leak from the nipples.

45. C. Prepregnant weight is usually achieved by 2 to 3 months after birth, not within the 6-week
postpartum period. Weight loss from diuresis, diaphoresis, and bleeding is about 9 pounds. Weight loss
continues during breastfeeding since fat stores developed during pregnancy and extra calories consumed
are used as part of the lactation process

46. D. Responses 1 and 3 are expected related to circulatory changes after birth. A temperature of 100.4°F
in the first 24 hours is most likely indicative of dehydration which is easily corrected by increasing oral
fluid intake. The findings in response 4 indicate a positive Homan sign and are suggestive of
thrombophlebitis and should be investigated further.

47. B. A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse
lochia and passage of clots. The first action would be to massage the fundus until firm, followed by 3 and
4, especially if the fundus does not become or remain firm with massage. There is no indication of a
distended bladder since the fundus is midline and below the umbilicus.

48. A. While the supine position is best for examining the abdomen, the woman should keep her arms at
her sides and slightly flex her knees in order to relax abdominal muscles and facilitate palpation of the
fundus. The bladder should be emptied before the check. A full bladder alters the position of the fundus
and makes the findings inaccurate. Although hands are washed before starting the check, clean (not
sterile) gloves are put on just before the perineum and pad are assessed to protect from contact with blood
and secretions.

49. D. Responses 1, 2, and 3 are all appropriate measures. The peribottle should be used in a backward
direction over the perineum. The flow should never be directed upward into the vagina since debris would
be forced upward into the uterus through the still-open cervix.

50. C. The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it
to relax. Responses 1, 2, and 4 are all effective measures to enhance and maintain contraction of the
uterus and to facilitate healing.
51. C. One week after birth the woman should exhibit behaviors characteristic of the taking-hold stage as
described in response 3. This stage lasts for as long as 4 to 5 weeks after birth. Responses 1 and 2 are
characteristic of the taking-in stage, which lasts for the first few days after birth. Response 4 reflects the
letting-go stage, which indicates that psychosocial recovery is complete.

52. D. Response 1 does not take into consideration the need for the new mother to be nurtured and have
her needs met during the taking-in stage. The behavior described is typical of this stage and not a
reflection of ineffective attachment unless the behavior persists. Mothers need to reestablish their own
well-being in order to effectively care for their baby.

53. A. Special time should be set aside just for the other children without interruption from the newborn.
Someone other than the mother should carry the baby into the home so she can give full attention to
greeting her other children. Children should be actively involved in the care of the baby according to their
ability without overwhelming them.

54. B. The focus of the taking-in stage is nurturing the new mother by meeting her dependency needs for
rest, comfort, hygiene, and nutrition. Once they are met, she is more able to take an active role, not only
in her own care but also the care of her newborn. Women express a need to review their childbirth
experience and evaluate their performance. Short teaching sessions, using written materials to reinforce
the content presented, are a more effective approach.