ATI RN
Postpartum Body Changes Questions
Question 1 of 5
A client is 36 hours post-cesarean section. Which of the following assessments would indicate that the client may have a paralytic ileus?
Correct Answer: D
Rationale: In this scenario, the correct answer is D) Absent bowel sounds. A paralytic ileus is a temporary paralysis of the bowel that can occur after abdominal surgery, including a cesarean section. Absent bowel sounds are a key indicator of a paralytic ileus because they suggest that peristalsis, the involuntary muscle contractions that move food through the digestive system, is not functioning properly. Option A) Abdominal striae are stretch marks on the skin and are not indicative of a paralytic ileus. Option B) Oliguria refers to decreased urine output and is not directly related to bowel function. Option C) Omphalocele is a congenital abdominal wall defect and is not a relevant assessment finding in this context. Educationally, understanding postpartum body changes, including potential complications like paralytic ileus, is crucial for healthcare providers caring for postpartum clients. Recognizing signs and symptoms early can help in prompt intervention and prevent complications. Nurses and midwives need to be skilled in assessing and managing postpartum women to ensure optimal recovery and well-being.
Question 2 of 5
A nurse on the postpartum unit is caring for two postoperative cesarean clients. One client had spinal anesthesia for the delivery and the other client had an epidural. Which of the following complications will the nurse monitor the spinal client for that the epidural client is much less high risk for?
Correct Answer: C
Rationale: The correct answer is C) Postural headache. In this scenario, the nurse will need to monitor the client who had spinal anesthesia for the development of a postural headache, a common complication associated with spinal anesthesia. This headache typically occurs due to a decrease in cerebrospinal fluid pressure after the procedure. Option A) Pruritus is a common side effect of both spinal and epidural anesthesia and is not specific to spinal anesthesia. Option B) Nausea can occur after both spinal and epidural anesthesia and is not a distinguishing factor between the two types of anesthesia. Option D) Respiratory depression is a serious complication associated with opioids used in both spinal and epidural anesthesia, so both clients are at risk for this complication irrespective of the type of anesthesia used. Educationally, understanding the differences in complications associated with spinal and epidural anesthesia is crucial for nurses caring for postoperative cesarean clients. By knowing the specific risks of each type of anesthesia, nurses can provide targeted monitoring and interventions to ensure optimal patient outcomes.
Question 3 of 5
The nurse is providing discharge counseling to a woman who is breastfeeding her baby. What should the nurse advise the woman to do if she should palpate tender, hard nodules in her breasts?
Correct Answer: A
Rationale: The correct answer is A) Gently massage the areas toward the nipple, especially during feedings. This advice is based on the understanding that tender, hard nodules in the breasts of a breastfeeding woman are likely due to blocked milk ducts, which can lead to mastitis if not addressed promptly. Massaging the area toward the nipple during feedings can help to release the blockage and improve milk flow. It is essential to maintain breastfeeding to prevent further complications and to ensure adequate milk supply for the baby. Option B) Apply ice to the areas between feedings is incorrect because applying ice can constrict blood vessels and potentially worsen the blockage. Heat therapy, such as warm compresses, is recommended instead to promote milk flow. Option C) Bottle feed for the next twenty-four hours is not advisable as it can lead to a decrease in milk production and can exacerbate the issue by not addressing the underlying cause of the blocked ducts. Option D) Apply lanolin ointment to the areas after each and every breastfeeding is also not the best course of action for treating blocked ducts. While lanolin ointment may be helpful for nipple soreness, it does not address the blockage within the milk ducts. Educationally, it is crucial for healthcare providers to understand the common postpartum breast issues that breastfeeding women may encounter, such as blocked ducts and mastitis, and be able to provide accurate and evidence-based counseling to support these women in successfully breastfeeding their babies. Providing clear guidance on how to manage these issues can help prevent complications and ensure a positive breastfeeding experience for both the mother and the baby.
Question 4 of 5
A client's vital signs and reflexes were normal throughout pregnancy, labor, and delivery. Four hours after delivery the client's vitals are 98.6°F, P 72, R 20, BP 150/100, and her reflexes are 4+. She has an intravenous infusion running with 20 units of Pitocin (oxytocin) added. Which of the following actions by the nurse is appropriate?
Correct Answer: B
Rationale: The correct answer is B) Notify the obstetrician of the findings. This is the appropriate action because the client's vital signs and reflexes are showing signs of postpartum preeclampsia, indicated by the elevated blood pressure of 150/100. Postpartum preeclampsia can develop within the first 48 hours after delivery, even if the client did not have hypertension during pregnancy. It is crucial to notify the obstetrician promptly for further evaluation and management to prevent complications. Option A) Nothing, because the results are normal, is incorrect as the elevated blood pressure and hyperreflexia are not normal findings postpartum. Option C) Discontinuing the intravenous immediately is not the priority in this situation. The focus should be on addressing the potential postpartum preeclampsia. Option D) Reassessing the client after fifteen minutes is not the most appropriate action when there are signs of potential postpartum preeclampsia present. Immediate notification of the obstetrician is necessary for timely intervention. Educationally, understanding the significance of postpartum preeclampsia and recognizing the signs and symptoms is crucial for nurses caring for postpartum clients. Prompt identification and intervention can prevent serious complications for the mother. Regular education and training on postpartum complications are essential to ensure optimal care and outcomes for postpartum clients.
Question 5 of 5
The nurse is caring for a couple who are in the labor/delivery room immediately after the delivery of a dead baby who exhibited visible birth defects. Which of the following actions by the nurse is appropriate?
Correct Answer: D
Rationale: In this scenario, option D is the most appropriate action for the nurse to take. Giving the parents a lock of the baby's hair and a copy of the footprint sheet allows them to have tangible keepsakes to remember their baby by. This gesture acknowledges the significance of the baby's existence and helps the parents in their grieving process. Option A is incorrect because discouraging the parents from naming the baby could invalidate their feelings and hinder their ability to properly mourn their loss. Option B is inappropriate as it undermines the parents' autonomy and their right to make decisions about their own emotional well-being. Option C is not the best choice as it may rush the parents through the grieving process by removing the baby too quickly without allowing them time for closure and saying their goodbyes. In an educational context, it is crucial for healthcare professionals to understand the importance of supporting families during difficult times like the loss of a baby. Providing compassionate care and respecting the parents' wishes in how they choose to grieve can positively impact their emotional healing process. Empathy, sensitivity, and personalized care are essential components of nursing care in such delicate situations.