Understanding the Postpartum NCLEX Questions
Question A postpartum nurse is assessing a client who delivered a healthy newborn 24 hours ago. Which of the following findings would the nurse prioritize for further evaluation?
A. Lochia rubra with small clots
B. Fundal height 1 cm below the umbilicus
C. Breast tenderness and engorgement
D. Temperature of 38.3°C (100.9°F)
E. Mild perineal discomfort
Rationale: A temperature of 38.3°C (100.9°F) 24 hours post-delivery could indicate an infection, such as endometritis, which requires immediate medical attention. Lochia rubra with small clots, fundal height 1 cm below the umbilicus, breast tenderness, and mild perineal discomfort are expected findings within the first 24 hours postpartum. Early identification and treatment of postpartum infections are crucial to prevent complications.
NCLEX Practice Quizzes: Test Your Knowledge (200+ Quizzes)
Question A nurse is providing care to a postpartum client. Which of the following actions should the nurse take first when assessing for uterine atony?
A. Check the client’s blood pressure and heart rate
B. Palpate the client’s fundus
C. Assess the client’s lochia for color and consistency
D. Encourage the client to void
E. Examine the perineal area for swelling and bruising
Rationale: Palpating the fundus is the first and most direct method to assess for uterine atony, which is a condition where the uterus fails to contract effectively after delivery. This condition can lead to significant postpartum hemorrhage. Assessing vital signs, lochia, encouraging voiding, and examining the perineal area are also important but secondary to the immediate need to assess the state of the uterus for atony.
Question Four days postpartum, a client reports discomfort and warmth in her left breast. Upon assessment, the nurse notes localized redness and edema. Which of the following interventions should the nurse prioritize?
A. Advising the client to stop breastfeeding immediately
B. Applying cold compresses to the affected area
C. Initiating antibiotic therapy
D. Encouraging frequent breastfeeding or pumping from the affected breast
E. Recommending over-the-counter pain relievers
Rationale: The symptoms described are indicative of mastitis, which is an inflammation of breast tissue that sometimes involves an infection. Encouraging frequent breastfeeding or pumping can help clear the blockage and prevent milk stasis, which is a common cause of mastitis. While antibiotics may be required if an infection is confirmed, the initial step is to promote milk flow. Cold compresses and pain relievers may provide symptom relief but do not address the underlying issue as effectively as maintaining milk flow does.
Question A postpartum nurse is educating a new mother on the signs of postpartum depression. Which of the following should the nurse include as a warning sign?
A. Experiencing baby blues for a few days after delivery
B. Feeling overwhelmed with the responsibilities of newborn care
C. Having difficulty sleeping when the baby is asleep
D. Losing interest in activities that were enjoyable before pregnancy
E. Worrying about the baby’s health and well-being
Rationale: Losing interest in activities that one used to enjoy is a significant warning sign of postpartum depression (PPD). While feelings of being overwhelmed, difficulty sleeping, and worrying about the baby’s health can be normal aspects of the postpartum period, a marked loss of interest in previously enjoyable activities suggests a deeper, more concerning level of emotional distress indicative of PPD. Educating new mothers about this and other signs of PPD is crucial for early identification and intervention.
Question A nurse is planning care for a postpartum client who is experiencing heavy lochia serosa and reports dizziness when standing. Which of the following interventions should the nurse prioritize?
A. Encouraging the client to increase fluid intake
B. Assisting the client with ambulation
C. Monitoring the client’s hemoglobin and hematocrit levels
D. Applying a cold pack to the perineal area
E. Teaching the client to perform Kegel exercises
Rationale: The client’s symptoms suggest potential postpartum hemorrhage or anemia, which could be due to excessive blood loss. Monitoring hemoglobin and hematocrit levels is essential to assess the severity of blood loss and determine the need for further intervention, such as blood transfusion. While increasing fluid intake, assisting with ambulation, and applying a cold pack may provide symptomatic relief, they do not address the potential underlying issue of significant blood loss as directly as monitoring blood levels does.
Question Three days postpartum, a client reports a headache that worsens when she stands up and improves when lying down. The nurse recognizes these symptoms as indicative of which condition?
A. Preeclampsia
B. Postpartum preeclampsia
C. Spinal headache
D. Migraine
E. Sinusitis
Rationale: A headache that worsens with standing and improves when lying down is characteristic of a spinal headache, which can occur after a spinal or epidural anesthetic. This type of headache is caused by leakage of cerebrospinal fluid at the puncture site. Preeclampsia and postpartum preeclampsia typically present with high blood pressure and other systemic symptoms, while migraines and sinusitis have different clinical presentations. Identifying a spinal headache is important for appropriate management, which may include hydration, caffeine, and in some cases, an epidural blood patch.
Question A postpartum client expresses concern about developing deep vein thrombosis (DVT) due to a family history of clotting disorders. Which of the following interventions should the nurse prioritize to reduce the risk of DVT?
A. Applying sequential compression devices while in bed
B. Encouraging the client to remain in bed and rest
C. Prescribing anticoagulant medication as a preventive measure
D. Recommending the use of over-the-counter pain relievers
E. Encouraging frequent ambulation
Rationale: Encouraging frequent ambulation is a key intervention to reduce the risk of DVT in postpartum clients, especially those with a history of clotting disorders. Movement helps to improve blood flow and reduce stasis, which are risk factors for the development of blood clots. While sequential compression devices can also be beneficial when the client is in bed, ambulation is more effective for those who are able to move. Anticoagulant medication may be indicated for some clients but would typically require a healthcare provider’s prescription based on a risk assessment.
Question A nurse is educating a postpartum client on measures to prevent mastitis. Which of the following instructions should the nurse include?
A. Limit breastfeeding to once every 4 hours
B. Wear a tight-fitting bra at all times
C. Ensure proper latch and positioning during breastfeeding
D. Apply heat to the breasts for 20 minutes before breastfeeding
E. Discontinue breastfeeding if the breasts become too full
Rationale: Ensuring proper latch and positioning during breastfeeding is crucial to prevent mastitis. Incorrect latch or poor positioning can lead to incomplete emptying of the breast and milk stasis, which increases the risk of infection and inflammation. Limiting breastfeeding, wearing tight-fitting bras, and discontinuing breastfeeding can actually contribute to the development of mastitis. Applying heat can help with milk flow but is not a preventive measure for mastitis like proper breastfeeding techniques are.
Question A postpartum client is being discharged from the hospital. Which of the following instructions should the nurse prioritize to prevent postpartum hemorrhage at home?
A. Take iron supplements as prescribed
B. Perform pelvic floor exercises daily
C. Monitor the amount and color of lochia
D. Maintain a diet high in protein and vitamins
E. Avoid lifting heavy objects for the first few weeks
Rationale: Monitoring the amount and color of lochia is essential for early detection of abnormal bleeding, which could indicate postpartum hemorrhage. While taking iron supplements, maintaining a nutritious diet, and avoiding heavy lifting are important postpartum care instructions, they do not directly help in the early detection of hemorrhage like monitoring lochia does. Pelvic floor exercises are important for recovery but also do not directly prevent hemorrhage.
NCLEX Questions: Focus on Postpartum
Question A nurse is reviewing the discharge instructions with a postpartum client. Which of the following signs should the nurse instruct the client to report immediately to a healthcare provider?
A. Experiencing mood swings in the first few weeks
B. Having breast tenderness while breastfeeding
C. Noticing an increase in lochia or a return to bright red bleeding after it has lightened
D. Feeling tired during the day
E. Experiencing discomfort during urination
Rationale: An increase in lochia or a return to bright red bleeding after it has lightened can be a sign of a secondary postpartum hemorrhage, which requires immediate medical attention. While mood swings, breast tenderness, daytime fatigue, and discomfort during urination can be common postpartum experiences, they do not typically indicate an emergency situation. Educating clients on the signs of potential complications is critical for early intervention and preventing severe outcomes.