ATI RN
Complication Postpartum Questions
Question 1 of 5
A client is receiving an epidural infusion of a narcotic for pain relief after a cesarean section. The nurse would report to the anesthesiologist if which of the following were assessed?
Correct Answer: A
Rationale: In this scenario, the correct answer is option A) Respiratory rate 8 rpm. This is the most critical assessment finding that would require immediate reporting to the anesthesiologist. The administration of a narcotic via epidural infusion can lead to respiratory depression as a side effect, especially when higher doses are used. A respiratory rate of 8 rpm is dangerously low and could indicate impending respiratory failure, a potentially life-threatening complication that requires immediate intervention. Complaint of thirst (option B) is a common side effect of narcotic medications but is not as urgent or concerning as respiratory depression. Urinary output of 250 mL/hr (option C) is within normal limits and not directly related to the administration of a narcotic. Numbness of feet and ankles (option D) is a common side effect of epidural anesthesia and does not indicate a critical issue requiring immediate attention. Educationally, this question highlights the importance of monitoring patients receiving epidural narcotic infusions postpartum for potential complications, particularly respiratory depression. Nurses must be vigilant in assessing vital signs and responding promptly to any signs of respiratory distress to ensure patient safety.
Question 2 of 5
The nurse is assessing the midline episiotomy on a postpartum client. Which of the following findings should the nurse expect to see?
Correct Answer: B
Rationale: In assessing a midline episiotomy on a postpartum client, the nurse should expect to see well-approximated edges (Option B). This indicates proper healing and closure of the incision site. Well-approximated edges suggest that the incision is healing as expected and reduces the risk of infection and other complications. Option A, moderate serosanguinous drainage, may be expected in the immediate postpartum period, but it is not a specific finding related to the assessment of the episiotomy incision site. Option C, an ecchymotic area distal to the episiotomy, suggests bruising, which is not a typical finding in a well-healing incision. Option D, an area of redness adjacent to the incision, could indicate inflammation or infection, which would be concerning and not expected in a healing episiotomy. Educationally, understanding the expected findings in assessing a postpartum episiotomy is crucial for nurses to provide appropriate care, monitor for complications, and intervene promptly if needed to promote optimal healing and recovery for postpartum clients.
Question 3 of 5
The nurse is developing a standard care plan for postpartum clients who have had midline episiotomies. Which of the following interventions should be included in the plan?
Correct Answer: C
Rationale: In developing a standard care plan for postpartum clients with midline episiotomies, including the intervention to teach the client to contract her buttocks before sitting (option C) is crucial. This intervention helps reduce tension and pressure on the episiotomy site, promoting healing and preventing complications such as wound dehiscence and infection. Option A is incorrect as removing stitches on the third postpartum day is premature and can disrupt the healing process. Option B may be necessary for pain management but does not directly address care specific to the episiotomy site. Option D is not recommended as routine irrigation with antibiotic solution can disrupt the natural healing process and increase the risk of developing antibiotic-resistant strains of bacteria. Educationally, this rationale highlights the importance of tailored care plans for specific postpartum complications, emphasizing the significance of interventions that promote healing and prevent complications in line with evidence-based practice.
Question 4 of 5
A nurse is assessing the fundus of a client during the immediate postpartum period. Which of the following actions indicates that the nurse is performing the skill correctly?
Correct Answer: B
Rationale: In postpartum care, assessing the fundus correctly is crucial to monitor uterine involution and prevent complications. Option B, where the nurse stabilizes the base of the uterus with the dependent hand, is the correct action. This technique helps accurately locate and evaluate the fundus, ensuring proper contraction and preventing excessive bleeding. Option A is incorrect because measuring fundal height with a paper centimeter tape is not the primary method of fundal assessment. Option C is incorrect as palpating the fundus with the fingertips alone may not provide enough support to accurately assess uterine tone. Option D is incorrect as a sterile vaginal exam is not necessary for fundal assessment and should not precede it in routine postpartum care. Educationally, understanding the correct technique for fundal assessment is essential for nurses caring for postpartum clients. Proper fundal assessment can help identify early signs of postpartum hemorrhage or other complications, allowing for timely intervention and improved patient outcomes.
Question 5 of 5
The nurse is assessing the laboratory report on a 2-day postpartum G1 P1001. The woman had a normal postpartum assessment this morning. Which of the following results should the nurse report to the primary health care provider?
Correct Answer: C
Rationale: In this scenario, the correct answer is option C) Hematocrit, 26%. This result indicates a low hematocrit level, which could suggest postpartum hemorrhage, a common complication after childbirth. Postpartum hemorrhage can be life-threatening and requires immediate medical attention. Reporting this result promptly can lead to timely intervention and prevent further complications for the mother. Option A) White blood cells, 12,500 cells/mm3, is within normal range and not indicative of a significant issue postpartum. Option B) Red blood cells, 4,500,000 cells/mm3, is also within normal limits and does not raise immediate concerns. Option D) Hemoglobin, 11 g/dL, though slightly lower than normal, is not as concerning as a low hematocrit level in the context of postpartum assessment. Educationally, understanding the significance of laboratory values in the postpartum period is crucial for nurses caring for postpartum women. Recognizing abnormal results and knowing when to escalate them to the primary healthcare provider is essential in providing safe and effective care to postpartum mothers. This knowledge can help prevent complications and improve outcomes for both the mother and the newborn.