ATI RN
Complication Postpartum Questions
Question 1 of 5
A 3-day-postpartum client questions why she is to receive the rubella vaccine before leaving the hospital. Which of the following rationales should guide the nurse 's response?
Correct Answer: B
Rationale: The correct answer is B) The client's immune system is highly responsive during the postpartum period. During the postpartum period, a woman's immune system is in a heightened state of responsiveness. This means that the body is more likely to mount a strong immune response to the rubella vaccine, leading to better protection against the disease. By administering the vaccine during this time, the woman can develop immunity more effectively and efficiently. Option A is incorrect because the timing of receiving the vaccine is more related to the woman's immune response rather than her obstetric status. Option C is incorrect as the decision to vaccinate is primarily for the woman's protection rather than the baby's risk. Option D is incorrect as the necessity of the vaccine is not based on insurance coverage but on the woman's health needs. In an educational context, understanding the timing of vaccination administration in relation to the body's immune response postpartum is crucial for healthcare providers to provide optimal care and protection for their patients. This knowledge helps ensure that vaccines are administered at the most effective times to maximize their benefits.
Question 2 of 5
A breastfeeding woman has been counseled on how to prevent engorgement. Which of the following actions by the mother shows that the teaching was effective?
Correct Answer: B
Rationale: The correct answer is B) She feeds her baby every 2 to 3 hours. Effective prevention of engorgement in breastfeeding mothers involves frequent and regular feeding sessions. Feeding the baby every 2 to 3 hours helps to ensure that the breasts are emptied regularly, which can help prevent engorgement. Engorgement occurs when breasts become overly full and can lead to discomfort and potential issues with milk supply. By feeding the baby frequently, the mother is helping to maintain a steady milk supply and prevent engorgement. Option A) "She pumps her breasts after each feeding" is not the most effective method for preventing engorgement. While pumping can help relieve engorgement, it is not as effective as regular breastfeeding in preventing the issue. Option C) "She feeds her baby 10 minutes on each side" may not be sufficient for emptying the breast completely, especially if the baby is a newborn or if there are any latching issues. Effective emptying of the breast is crucial in preventing engorgement. Option D) "She supplements each feeding with formula" is not recommended for preventing engorgement. Supplementing with formula can interfere with establishing a robust milk supply and may lead to further issues with engorgement. In an educational context, it's important to emphasize to breastfeeding mothers the significance of frequent and effective breastfeeding in preventing engorgement. Encouraging mothers to feed on demand, ensuring proper latching techniques, and seeking support from lactation consultants can all contribute to successful breastfeeding and prevention of engorgement.
Question 3 of 5
A G2 P2002, who is postpartum 6 hours from a spontaneous vaginal delivery, is assessed. The nurse notes that the fundus is firm at the umbilicus, there is heavy lochia rubra, and perineal sutures are intact. Which of the following actions should the nurse take at this time?
Correct Answer: A
Rationale: In this scenario, the correct action is option A) Do nothing. This is a normal finding. The rationale behind this choice is based on the assessment findings provided. The firm fundus at the umbilicus indicates proper uterine contraction, which is essential for preventing postpartum hemorrhage. The heavy lochia rubra is expected in the immediate postpartum period, indicating the normal shedding of the uterine lining. The intact perineal sutures suggest no immediate need for intervention in that area. Option B) Massage the woman's fundus is incorrect because the fundus is already firm, indicating proper contraction. Unnecessary fundal massage can actually cause uterine overstimulation and potential complications. Option C) Take the woman to the bathroom to void is not the priority at this time. While voiding is important postpartum, it is not urgent in this situation where the fundus assessment takes precedence. Option D) Notify the woman's primary health care provider is also unnecessary at this point since the assessment findings indicate normal postpartum progress. It is within the nurse's scope of practice to manage these routine postpartum assessments and care. This educational context highlights the importance of recognizing normal postpartum findings and understanding when intervention is needed. It emphasizes the significance of thorough assessment skills in providing appropriate care to postpartum women.
Question 4 of 5
A multigravid, postpartum woman reports severe abdominal cramping whenever she nurses her baby. Which of the following responses by the nurse is appropriate?
Correct Answer: D
Rationale: In this scenario, the correct response is option D: Discuss the action of breastfeeding hormones. This is the appropriate response as it addresses the underlying cause of the woman's symptoms. When a woman breastfeeds, her body releases oxytocin, which helps the uterus contract and return to its pre-pregnancy size. This contraction can lead to abdominal cramping, especially during the early postpartum period. Option A is incorrect because suggesting bottle feeding could deprive the baby of the benefits of breastfeeding and hinder the establishment of breastfeeding. Option B, massaging the fundus, is not directly related to the woman's symptoms of cramping while nursing. Option C, feeding in an alternate position, may provide some relief but does not address the root cause of the cramping. From an educational standpoint, it is important for nurses to understand the physiological changes that occur during breastfeeding and how they can manifest as symptoms in postpartum women. By discussing the action of breastfeeding hormones with the patient, the nurse can provide valuable information and reassurance, empowering the woman to continue breastfeeding while managing her symptoms effectively.
Question 5 of 5
A breastfeeding mother states that she has sore nipples. In response to the complaint, the nurse assists with 'latch on ' and recommends that the mother do which of the following?
Correct Answer: C
Rationale: In the context of postpartum complications related to breastfeeding, the correct answer C) Rotate the baby's positions at each feed is the most appropriate recommendation for a mother experiencing sore nipples. This is because changing the baby's positions during feeding can help ensure proper latch and reduce pressure on specific areas of the nipple, promoting better comfort and healing. Option A) Using a nipple shield at each breastfeeding may not address the underlying issue of improper latch or positioning, and it can sometimes interfere with effective milk transfer, potentially leading to further nipple soreness. Option B) Cleansing the nipples with soap 3 times a day can strip the skin of natural oils, causing dryness and irritation, which can exacerbate soreness and delay healing. Option D) Bottle feeding for 2 days then resuming breastfeeding is not recommended as it can disrupt the establishment of breastfeeding and potentially lead to issues like nipple confusion or decreased milk supply. Educationally, it's crucial to emphasize the importance of proper latch and positioning in breastfeeding to prevent complications like sore nipples. Teaching mothers techniques like rotating the baby's positions can help optimize breastfeeding success and support maternal comfort and well-being.