NCLEX-Style Questions

A nurse is assessing a postpartum client who delivered 24 hours ago. The nurse notes the client's fundus is soft, boggy, and located at U/2. Which of the following is the nurse's priority action?

• Encourage the client to ambulate to the bathroom.

• Administer pain medication as ordered.

• Perform fundal massage immediately.

• Document the finding and reassess in 30 minutes.

A postpartum client, 3 days post-delivery, reports a foul odor from her lochia and states she has not had a bowel movement since delivery. Which finding is the priority for the nurse to address?

• The client's lack of a bowel movement.

• The foul odor of the lochia.

• The client's perceived discomfort.

• The need for constipation teaching.

Tags

NGSS.HS-LS1-3

A nurse is providing discharge teaching to a postpartum client who is not breastfeeding. Which information regarding breast care should the nurse include?

• Encourage frequent nipple stimulation to promote milk cessation.

• Advise applying a binder or tight bra, ice, and cabbage leaves.

• Instruct the client to express milk frequently to relieve engorgement.

• Inform the client that lactation will cease within 2-3 days post-birth.

A nurse is assessing a postpartum client who delivered vaginally yesterday. The nurse notes the client's perineum is edematous and bruised with small superficial lacerations. Which nursing intervention is most appropriate to promote comfort for this client?

• Apply warm compresses to the perineum.

• Encourage frequent ambulation.

• Offer ice packs for the first 24 hours.

• Advise frequent douching.

A postpartum client who had a C-section is complaining of calf pain. Upon assessment, the nurse notes redness, tenderness, and warmth in the client's right calf, and is unable to palpate the pedal pulse on that side. The nurse suspects thrombophlebitis. Which action is the nurse's priority?

• Elevate the client's leg and apply a warm compress.

• Encourage the client to ambulate to promote circulation.

• Notify the healthcare provider immediately.

• Administer an analgesic and reassess in 30 minutes.

A nurse is providing teaching to a non-lactating postpartum client regarding the resumption of ovarian function. Which statement by the client indicates understanding?

• I should expect my period to resume in about 4 weeks.

• I cannot ovulate until after my first menstrual period.

• I could ovulate as early as 27 days after giving birth.

• I will not need to use contraception for at least 6 months.

A nurse is reviewing the physiological changes in the postpartum period. Which of the following findings would be considered abnormal and require further assessment? (Select all that apply).

• Temperature of 38.5°C (101.3°F) at 36 hours postpartum.

• Pulse

A nurse is assessing a client who is 1 day postpartum. Which of the following findings should the nurse identify as abnormal?

• Temperature of 38.5°C (101.3°F) at 36 hours postpartum.

• Pulse rate of 98 beats/min.

• Blood pressure of 150/92 mmHg.

• White blood cell count of 22,000 cells/mm³ on day 2 postpartum.

• Uterine fundus 1 cm above the umbilicus (1/U) on day 1 postpartum.

A client with gestational diabetes (GDM) is in labor. The nurse understands that appropriate intrapartum care for this client includes which of the following?

• Monitoring blood glucose levels every 4 hours.

• Maintaining blood glucose levels between 80-90 mg/dL and 110 mg/dL.

• Discontinuing insulin drip if active labor is established.

• Initiating IV fluids of D5LR when glucose levels are below 70 mg/dL.

• Monitoring for signs of shoulder dystocia.

A nurse is preparing to provide discharge teaching to a client diagnosed with Gestational Diabetes Mellitus (GDM) who has just delivered. Which information is most important for the nurse to emphasize regarding future health management?

• GDM clients will no longer need to monitor their blood glucose levels.

• There is an up to 70% chance of developing diabetes later in life.

• Lifestyle modifications are no longer necessary once GDM resolves.

• Blood glucose reassessment should only occur if symptoms of diabetes appear.