ATI RN
Postpartum Body Changes Questions
Question 1 of 5
A home care nurse is visiting a breastfeeding client who is 2 weeks postdelivery of a 7-lb baby girl over a midline episiotomy. Which of the following findings should take priority?
Correct Answer: D
Rationale: In this scenario, the priority finding is option D) Client yells at the baby for crying. This behavior raises concerns about the client's mental and emotional well-being, as well as the potential for postpartum depression or other mental health issues. As a home care nurse, ensuring the safety and well-being of both the mother and baby is crucial. Option A) Lochia is serosa, while important, does not pose an immediate threat to the client or her baby's safety. Option B) Client cries throughout the visit may indicate emotional distress, but it is not as urgent as the potential risk of harm to the baby from the client yelling. Option C) Nipples are cracked is a common issue in breastfeeding mothers but does not take precedence over the safety of the baby in this situation. Educationally, this scenario highlights the importance of assessing not only physical but also mental health status in postpartum clients. It underscores the need for healthcare providers to be vigilant for signs of postpartum depression or other mental health concerns, as early intervention is key to ensuring the well-being of both the mother and baby. It also emphasizes the critical role of the nurse in providing holistic and comprehensive care to postpartum clients.
Question 2 of 5
A nurse massages the atonic uterus of a woman who delivered 1 hour earlier. The nurse identifies the nursing diagnosis: Risk for injury related to uterine atony. Which of the following outcomes indicates that the client's condition has improved?
Correct Answer: A
Rationale: In the postpartum period, uterine atony can lead to excessive bleeding and poses a risk for injury to the mother. Massaging the atonic uterus helps to promote uterine contractions and prevent further bleeding. The correct answer, option A) Moderate lochia flow, indicates an improvement in the client's condition. Lochia is the postpartum vaginal discharge containing blood, mucus, and uterine tissue. A moderate flow suggests that the uterus is contracting effectively to control bleeding. Option B) Decreased pain level, while important for the client's comfort, does not directly indicate an improvement in uterine atony. Option C) Stable blood pressure is a crucial parameter to monitor but may not specifically reflect the resolution of uterine atony. Option D) Fundus above the umbilicus is actually a concerning finding as it suggests uterine atony as the fundus should be firm and at or below the level of the umbilicus in the immediate postpartum period. Educationally, understanding the significance of uterine atony and its management postpartum is vital for nurses caring for postpartum clients. Recognizing the signs of uterine atony, implementing appropriate interventions like uterine massage, and evaluating outcomes such as lochia flow are essential skills in preventing postpartum complications.
Question 3 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 4 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 5 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.