ATI RN
Postpartum Body Changes Questions
Question 1 of 5
A breastfeeding client is being seen in the emergency department with a hard, red, warm nodule in the upper outer quadrant of her left breast. Her vital signs are: T 104.6°F, P 100, R 20, and BP 110/60. She has a recent history of mastitis and is crying in pain. Which of the following nursing diagnoses is highest priority?
Correct Answer: B
Rationale: In this scenario, the highest priority nursing diagnosis is B) Infection. The client's presentation with a hard, red, warm nodule in the breast, elevated temperature, history of mastitis, and severe pain indicates a potential breast infection, which requires immediate attention to prevent further complications like abscess formation or sepsis. Option A) Ineffective breastfeeding is incorrect as the primary concern here is addressing the infection to ensure the client's health and safety. Option C) Ineffective individual coping may be a secondary concern once the infection is under control. Option D) Pain is important, but treating the underlying infection takes precedence. Educationally, it is crucial for nurses to prioritize nursing diagnoses based on the urgency of the client's condition. Understanding the signs and symptoms of infections like mastitis in breastfeeding clients is essential for early identification and intervention to prevent serious complications. Nurses must be prepared to act swiftly in cases of suspected infections to provide appropriate care and support to their clients.
Question 2 of 5
A client who received an epidural for her operative delivery has vomited twice since the surgery. Which of the following prn medications ordered by the anesthesiologist should the nurse administer at this time?
Correct Answer: A
Rationale: In this scenario, the correct answer is A) Reglan (metoclopramide). Reglan is a prokinetic agent that helps to increase gastric motility and reduce nausea and vomiting. In the case of the client who received an epidural for her operative delivery and has vomited twice since the surgery, Reglan would be the most appropriate medication to administer to help alleviate her symptoms. Option B) Demerol (meperidine) is a narcotic analgesic and is not indicated for treating nausea and vomiting. Option C) Seconal (secobarbital) is a barbiturate that is used for sedation and anxiety, not for managing nausea and vomiting. Option D) Benadryl (diphenhydramine) is an antihistamine that can help with allergies and insomnia but is not the best choice for treating postoperative nausea and vomiting. From an educational perspective, it is important for nurses to understand the rationale behind selecting the appropriate medication for managing common postpartum complications like nausea and vomiting. By knowing the pharmacological actions of different medications, nurses can provide safe and effective care to their postpartum clients. Understanding the correct use of medications in specific clinical situations is crucial for promoting positive patient outcomes and ensuring patient safety.
Question 3 of 5
A postpartum woman has been diagnosed with postpartum psychosis. Which of the following is essential to be included in the family teaching for this client?
Correct Answer: A
Rationale: The correct answer is A) The woman should never be left alone with her infant. Postpartum psychosis is a severe condition that can lead to irrational thoughts and behaviors, including harm to oneself or the infant. It is crucial to ensure the safety of both the mother and the baby. Leaving the woman alone with her infant can pose a serious risk, so constant supervision and support are essential. Option B is incorrect because symptoms of postpartum psychosis can last much longer than one week. This condition requires immediate attention and ongoing treatment to ensure the well-being of the mother and her child. Option C is incorrect because clinical response to medications can vary from individual to individual. While medications may be a part of the treatment plan, they are not a guarantee of poor response. Option D is incorrect as vital sign assessments every two days may not be sufficient for monitoring the well-being of a woman with postpartum psychosis. Close monitoring and support are crucial in managing this condition effectively. Educationally, it is important for families to understand the seriousness of postpartum psychosis and the precautions needed to ensure the safety of both the mother and the infant. Providing this information can help families support the woman in getting the necessary treatment and care.
Question 4 of 5
A nurse administered RhoGAM to a client whose blood type is A+ (positive). Which of the following responses would the nurse expect to see? Select all that apply.
Correct Answer: D
Rationale: In this scenario, the correct response is D) Swelling at the injection site. RhoGAM is given to Rh-negative individuals to prevent the development of Rh antibodies, particularly in pregnant women to prevent hemolytic disease in the newborn. In an Rh-positive individual like the client with blood type A+, administering RhoGAM should not lead to adverse reactions like fever, flank pain, or dark-colored urine. Swelling at the injection site is an expected response due to the nature of the injection. It is a common local reaction to injections in general and is not typically concerning. This localized swelling usually resolves on its own without complications. Educationally, it is important for nurses to understand the rationale behind administering RhoGAM and the potential responses associated with it. This knowledge ensures safe and effective care for pregnant women and their babies, preventing complications related to Rh incompatibility. Nurses should be able to differentiate between expected and abnormal responses to medications to provide appropriate monitoring and interventions.
Question 5 of 5
The nurse is caring for a client, G3 P2002, whose infant has been diagnosed with a treatable birth defect. Which of the following is an appropriate statement for the nurse to make?
Correct Answer: D
Rationale: The correct answer is D) It is appropriate for you to cry at a time like this. Rationale: - The correct answer acknowledges and validates the client's emotions, indicating empathy and understanding of the difficult situation the client is facing. It recognizes that crying is a natural response to emotional stress and provides a supportive approach. Why the other options are wrong: - Option A: This response minimizes the client's feelings by comparing the situation to a potentially worse scenario. It does not address the client's current emotional state or offer support. - Option B: This response focuses on the health of the client's other children, which may come across as dismissive of the client's current concerns and emotions. - Option C: This response imposes personal beliefs on the client and may not align with the client's own beliefs or values. It does not address the client's emotional needs or provide support. Educational context: In the postpartum period, mothers may experience a wide range of emotions, especially when faced with challenges such as a newborn with a birth defect. As a nurse, it is crucial to provide compassionate and empathetic care, acknowledging the client's feelings and offering support. Validating the client's emotions and providing a safe space for expression can help promote emotional well-being and facilitate coping during a challenging time.