A client who is 2 hours postpartum following a cesarean birth has a history of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care?

Questions 28

ATI RN

ATI RN Test Bank

ATI Maternal Newborn Practice Questions Questions

Question 1 of 5

A client who is 2 hours postpartum following a cesarean birth has a history of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care?

Correct Answer: D

Rationale: The correct intervention for a client who is 2 hours postpartum following a cesarean birth with a history of thromboembolic disease is to have the client ambulate. Early ambulation is crucial in preventing complications such as deep vein thrombosis in postpartum clients. Applying warm, moist heat, massaging the legs, or placing pillows under the knees do not directly address the risk of thromboembolic disease in this scenario.

Question 2 of 5

A healthcare provider is preparing to administer an injection of Rho (D) immunoglobulin. The provider should understand that the purpose of this injection is to prevent which of the following newborn complications?

Correct Answer: B

Rationale: Rho (D) immunoglobulin is given to Rh-negative individuals to prevent hemolytic disease of the newborn (HDN) caused by Rh incompatibility between the mother and the fetus. If an Rh-negative mother carries an Rh-positive fetus, there is a risk of sensitization during pregnancy or childbirth. Sensitization can lead to the production of antibodies that may attack Rh-positive red blood cells in future pregnancies, potentially causing severe hemolytic disease in the newborn, including complications like hydrops fetalis. Hydrops fetalis is a condition characterized by severe edema and fetal organ enlargement due to severe anemia and heart failure in the fetus.

Question 3 of 5

A newborn's mother is positive for the hepatitis B surface antigen. Which of the following should the infant receive?

Correct Answer: C

Rationale: In the scenario where a newborn's mother is positive for hepatitis B surface antigen, the infant should receive both hepatitis B immune globulin and hepatitis B vaccine within 12 hours of birth. This is crucial to provide passive and active immunity against the Hepatitis B virus. Hepatitis B immune globulin provides immediate protection by giving passive immunity, while the vaccine stimulates active immunity in the infant. Administering both within 12 hours of birth is important to prevent vertical transmission of the virus.

Question 4 of 5

A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

Correct Answer: A

Rationale: Delegating the task of providing a sitz bath to a client with a fourth-degree laceration and who is 2 days postpartum to the assistive personnel (AP) is appropriate. This task involves assisting the client with personal hygiene and comfort measures that can be safely performed by the AP under the supervision and direction of the nurse. Tasks like observing redness on the breast, monitoring vital signs during admission for gestational hypertension, and changing perineal pads may require a higher level of assessment and nursing judgment, making them more appropriate for the nurse to perform.

Question 5 of 5

During an assessment, a nurse is evaluating a pregnant client for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Access More Questions!

ATI RN Basic


$89/ 30 days

ATI RN Premium


$150/ 90 days

Similar Questions