Mohammad Jabber M Paudac BSN 2A

NCM 107 Group 3 Ma'am Sylvia Garcia

NCLEX Questions
1. 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
Rationale: Lochia, the discharge present after birth, is red for the first 1 to 3 days and
gradually decreases in amount. Foul smelling or purulent lochia usually indicates
infection, and these findings are not normal.

2. 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.
Rationale: The nurse should ask the mother to empty her bladder so that an accurate
assessment can be done.

3. A nurse is teaching a postpartum client about breast-feeding. Which of the following

instructions should the nurse include?
A. The diet should include additional fluids
B. Prenatal vitamins should be discontinued
C. Soap should be used to cleanse the breasts.
D. Birth control measures are unnecessary while breast-feeding.
Rationale: A diet for a breast-feeding patient should include additional fluids. Prenatal
vitamins should be taken as prescribed and soap should not be used on the breast
because it removes natural oils which increases the chance of cracked nipples. Breast-
feeding is not a sole method of contraception, so birth control measures should be
resumed.

4. A nurse assigned to care for a postpartum client plans to promote parental-infant

bonding by encouraging the parents to:
A. Use a low-pitched voice to speak to the infant
B. Allow the nursing staff to assume the infant care during hospitalization so they may
rest
 C. Hold and cuddle the infant closely
D. Allow the infant to sleep in the parental bed between the parents
Rationale: Holding the infant close so that body warmth can be felt initiates a positive
experience for the parent. It is also self-quieting and consoles the infant.

5. After a precipitous delivery, a nurse notes that the new mother is passive and only
touches her newborn infant briefly with her fingertips. The nurse should do which of
the following to help the woman process what has happened?
A. Encourage the mother to breast-feed soon after birth.
B. Support the mother in her reaction to the newborn infant.
C. Tell the mother that it is important to hold the newborn infant.
D. Document a complete account of the mother's reaction on the birth record.
Rationale: Precipitous labor is labor that lasts less than 3 hours. Women who have
experienced precipitous labor often describe the feelings of disbelief that their labor
progressed so rapidly. It is best at this time to support the mother in the moment and
only this choice acknowledges the mother's feelings.