Answer Key:

I.

MULTIPLE CHOICE (20 items)

1. D - Ask the mother to urinate and empty her bladder. 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 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.
2. D-Taking-in phase. 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.
3. B- Massage the fundus until it is firm.- If the uterus is not contracted firmly, initial 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
positioning the client on the side would not assist in managing uterine atony.
4. B-Blood pressure. 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.
5. A- The diet for a breast feeding client should include additional fluids. Prenatal vitamins should be taken
as prescribed, and soap should not be used on the breasts because it tends to remove natural oils, which
increases the chance of cracked nipples. Breastfeeding is not a method of contraception, so birth control
measures should be resumed.
6. A- 3 days postpartum. After birth, the nurse should auscultate the client's abdomen in all 4 quadrants to
determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days postpartum.
Surgery, anesthesia, and the use of opiods and pain control agents also contribute to the longer period of
altered bowel functions. B,C, &D are incorrect.
7. D-The client should avoid getting pregnant for 3 months after the vaccine because the vaccine has
teratogenic effects. 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.
8. A- Soft, non-tender; colostrum is present. Breasts are essentially unchanged for the first two to three
days after birth. Colostrum is present and may leak from the nipples.
9. C- Notify the physician. Normally, a few small clots may be noted in the lochia in the first 1 to 2 days after
birth from pooling of blood in the vagina. ots larger than 1 cm are considered abnormal. The cause of these
closts, such as uterine atony or retained placental fragments, needs to be determined and treates to prevent
further blood loss. Although the finding would be documented the approriate action is to notify the notify the
physician . Reassessing the client in 2 hours would delay necessary treatment. Increasing oral intake of fluids
would not be a helpful action in this situation
10. C- Instruct the client to request help when getting out of bed Orthostatic hypotension may be evident
during the first 8 hours after birth. Feelings of faintness or dizziness are signs that caution the nurse to focus
interventions on the client's safety/ The nurse should advise the client to get help first few times she gets out
of bed. A, is not a helpful action in this situation and would not relieve the symptoms. B, requires a health care
provider's prescription. D, is unnecessary
11. D-I need to stop breastfeeding until this condition resolves.. 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.
12. B- Indicates presence of infection. 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.
13. A- Prolactin. Prolactin is a hormone named originally after its function to promote milk production (lactation)
in mammals in response to the suckling of young after birth. I
14. D-lochia rubra- Lochia rubra -- the first three to five days of postpartum vaginal discharge. Lochia rubra
appears very bright red and contains a large amount of red blood cells. Lochia serosa -- occurs until about the
tenth day after childbirth. Lochia serosa is thinner than lochia rubra and is brownish or pink. Lochia alba -occurs next, lasting up to six weeks after childbirth. Lochia alba is white or yellowish-white.
15. D- The multiparous client who have delivered a large fetus after oxytocin induction . The causes of
postpartum hemorrhage include uterine atony; laceration of the vagina; hematoma development in the cervix,
perineum, or labia; and retained placental fragments. Predisposing factors for hemorrhage include a previous
history of postpartum hemorrhage, placenta previa, abruptio placentae, overdistention of the uterus from
polyhydramnios, multiple gestation, a large neonate, infection, multiparity, dystocia, CS. The multiparous client
who have delivered a large fetus after oxytocin induction has more risk factors associated with postpartum
hemorrhage than the other clients.
16. B-Oxytocin. After birth, oxytocin contracts the smooth muscle layer of band-like cells surrounding the alveoli
to squeeze the newly produced milk into the duct system. Oxytocin is necessary for the milk ejection reflex,
or let-down to occur.
17. D- I should wash my nipples daily with soap and water." Mastitis is inflammation of the breast as a result
of infection. It is generally caused by an organism that enters through an injured area of the nipples, such as a
crack or blister. Measures to prevent the development of mastitis include changing nursing pads when they
are wet and avoiding continuous pressure on the breasts. Sop is drying and could lead to cracking of the
nipples, and the client should be instructed to avoid using soap on the nipples. The mother is taught about the
importance of hand washing and that she should breast feed every 2-3 hours.
18. D- Multigravidas are at increased risk for uterine atony. Multiple full-term pregnancies and deliveries
result in overstretched uterine muscles that do not contract efficiently and bleeding may ensue.
19. C-Hematuria, ecchymosis, and epistaxis. 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.
20. C- Tone, Trauma, Tissue, Thrombin. The causes of PPH have been described as the "four T's":
Tone: uterine atony, distended bladder.
Tissue: retained placenta or clots.
Trauma: lacerations of the uterus, cervix, or
Thrombin: pre-existing or acquired
vagina.
coagulopathy.