ATI RN
Complications of Postpartum Questions
Question 1 of 5
A postpartum cesarean patient comes into the rural health clinic at 1 week postdelivery for an incision check by the nurse. The vital signs reveal a temperature of 100.5°F, and the patient reports moderate foul-smelling lochia. The nurse determines that the skin incision is healing normally, but when palpating the uterus, she discovers the patient to have uterine and pelvic tenderness. What are the most appropriate nursing actions?
Correct Answer: D
Rationale: The correct answer is D. In this scenario, the nurse should explain to the patient that the incision is healing well and provide appropriate measures to manage the elevated temperature and pain. It is essential to address the patient's current symptoms and provide symptomatic relief while ensuring proper healing of the incision. Continuing with the ordered pain medication and advising the patient to take Tylenol for the elevated temperature are appropriate actions to manage the immediate concerns. Option A is incorrect because jumping to conclusions about a uterine infection without further assessment or diagnostic tests can lead to unnecessary anxiety for the patient. Option B is incorrect as it dismisses the concerning symptoms of fever and foul-smelling lochia, which could indicate an infection or other complication. Option C is incorrect because the patient's symptoms of uterine tenderness and elevated temperature require immediate attention and should not be dismissed as normal postoperative pain. In an educational context, it is crucial for nurses to recognize and respond to postpartum complications promptly. Understanding the signs and symptoms of postpartum infections, such as fever and foul-smelling discharge, is essential for providing appropriate care and preventing potential complications. Nurses play a key role in early identification and intervention in postpartum complications to ensure optimal patient outcomes.
Question 2 of 5
One hour after a woman gives birth vaginally, the nurse notes that her fundus is firm, 2 fingerbreadths above the umbilicus, and deviated to the right. Lochia rubra is moderate. Her perineum is slightly edematous, with no bruising; an ice pack is in place. The priority nursing action is to:
Correct Answer: B
Rationale: The priority nursing action in this scenario is to have the woman empty her bladder (Option B). This is essential because a full bladder can displace the uterus, leading to potential complications such as uterine atony or hemorrhage. By ensuring the bladder is empty, the nurse helps the uterus contract effectively, reducing the risk of postpartum hemorrhage. Option A is incorrect because while it is important to document normal assessments, addressing the full bladder takes precedence due to its potential impact on uterine contraction. Option C is incorrect as removing the ice pack could lead to increased swelling and discomfort in the perineal area, which is not a priority at this time. Option D is incorrect because increasing the rate of oxytocin infusion without addressing the full bladder first may not effectively manage the situation. In an educational context, it is crucial for nurses to prioritize interventions based on their potential impact on patient outcomes. Understanding the physiological processes postpartum and how different factors can influence them is key to providing safe and effective care to women during the postpartum period. This case highlights the importance of basic nursing assessments and interventions in preventing complications following childbirth.
Question 3 of 5
The nurse's initial response if a pulmonary embolism is suspected should be to:
Correct Answer: B
Rationale: In the scenario of suspected pulmonary embolism in a postpartum patient, the nurse's initial response should be to raise the head of the bed and administer oxygen (Option B). This action is crucial as it helps to improve oxygenation and perfusion to vital organs, which is essential in managing a potential pulmonary embolism. Raising the head of the bed promotes optimal lung expansion and ventilation, while administering oxygen supports adequate oxygenation. These interventions are fundamental in stabilizing the patient's condition and preventing further complications related to hypoxia or respiratory distress. The other options are incorrect for several reasons: A) Starting a second IV line and preparing for transfusion is not the priority in a suspected pulmonary embolism. Immediate respiratory support takes precedence over initiating additional IV access. C) Inserting a catheter to monitor urine output is not the most urgent action in this critical situation. Monitoring urine output is important for assessing renal function but is not the primary intervention needed for a suspected pulmonary embolism. D) Lowering the head of the bed and elevating the legs is contraindicated in a suspected pulmonary embolism as it can further compromise oxygenation by impeding venous return to the heart, potentially exacerbating the embolism and leading to hemodynamic instability. In an educational context, understanding the prioritization of interventions in emergencies like pulmonary embolism is essential for nurses to provide safe and effective care. Critical thinking skills and quick decision-making are crucial in such situations to ensure the best outcomes for patients.
Question 4 of 5
Postpartum teaching related to urinary health should emphasize:
Correct Answer: C
Rationale: In postpartum teaching related to urinary health, emphasizing the importance of cleansing the perineum in a front-to-back direction (Option C) is crucial. This practice helps prevent the introduction of harmful bacteria from the rectal area to the urinary tract, reducing the risk of urinary tract infections (UTIs) and other complications. Option A, drinking any type of fluid whenever thirsty, is a general recommendation for overall hydration but not specifically related to urinary health postpartum. Option B, allowing the bladder to fill to promote emptying, is incorrect as frequent emptying of the bladder is important to prevent UTIs. Option D, eating two servings of acidic fruits or vegetables each day, is not directly related to perineal hygiene or urinary health. In an educational context, teaching postpartum individuals about proper perineal care is essential for their overall well-being and to prevent complications such as UTIs. Emphasizing the correct technique of cleansing from front to back can empower individuals to take proactive steps in maintaining their urinary health during the postpartum period.
Question 5 of 5
A breastfeeding woman develops mastitis. She tells the nurse that she will feed her baby formula instead of breastfeeding until the infection is healed. The best nursing response is that:
Correct Answer: A
Rationale: In this scenario, the correct response is option A: Emptying the breast is important to prevent an abscess. This is the best nursing response because continuing to empty the breast through breastfeeding or pumping is crucial in treating mastitis and preventing the development of an abscess. Option B is incorrect because using a tight breast binder or bra can actually worsen engorgement and impede milk flow, exacerbating the mastitis. Option C is incorrect as there is no direct correlation between drinking extra fluids and weaning during mastitis treatment. Option D is incorrect because breastfeeding should not be resumed solely based on normal temperature; it is essential to ensure proper treatment and resolution of the infection. From an educational perspective, it is important for healthcare providers to understand the significance of breast emptying in managing mastitis. By continuing to breastfeed or pump, the mother can promote drainage of the infected milk ducts, alleviate symptoms, and prevent complications like abscess formation. Educating mothers on the importance of breast emptying can help them make informed decisions regarding breastfeeding even in the presence of mastitis.