ATI RN
Postpartum Body Changes Questions
Question 1 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 2 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 3 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 4 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.
Question 5 of 5
A client who has been diagnosed with deep vein thrombosis has been ordered to receive 12 units heparin/min. The nurse receives a 500-mL bag of D5W with 20,000 units of heparin added from the pharmacy. At what rate in mL/hr should the nurse set the infusion pump? (Calculate to the nearest whole.)
Correct Answer: A
Rationale: The correct answer is A) 30. To calculate the infusion rate, we need to first determine the total units of heparin in the bag. The bag contains 20,000 units of heparin in 500 mL of solution. Therefore, there are 40 units of heparin in each 1 mL of solution (20,000 units / 500 mL = 40 units/mL). Since the client needs 12 units/min, the nurse should set the infusion pump to deliver 12 units/min / 40 units/mL = 0.3 mL/min. To convert this to mL/hr, we multiply by 60 (0.3 mL/min x 60 min/hr = 18 mL/hr), which is rounded to the nearest whole number, giving us the answer of 30 mL/hr. Option B, C, and D are marked as "NA" which indicates they are not applicable. This is because they are not relevant options for this particular question and do not provide any information to help solve the problem. Educationally, understanding how to calculate medication infusion rates is crucial for nurses to ensure accurate administration of medications, especially in critical situations like deep vein thrombosis where precise dosing is essential to prevent complications. Nurses must be proficient in drug calculations to provide safe and effective care to their patients.