ATI RN
Ethical Issues in Maternal Newborn Nursing Questions
Question 1 of 5
A woman gave birth to an infant+2:230 boy 10 hours ago. Where does the nurse expect to locate this woman's fundus?
Correct Answer: A
Rationale: The correct answer is A) 1 centimeter above the umbilicus. In the immediate postpartum period, the fundus, which is the top of the uterus, is expected to be located at this specific point. This is because after childbirth, the uterus begins to contract and gradually descends back into the pelvis. At 10 hours postpartum, the fundus should be around this location, indicating appropriate uterine involution. Option B) 2 centimeters below the umbilicus is incorrect as the fundus should be ascending, not descending, at this point in time. Option C) Midway between the umbilicus and the symphysis pubis is also incorrect as this would be an expected fundal location in the immediate hours after birth, not at 10 hours postpartum. Option D) Nonpalpable abdominally is incorrect as the fundus should be palpable, although it may be slightly higher or lower depending on the stage of postpartum recovery. Understanding the location of the fundus postpartum is crucial for maternal newborn nurses as it provides essential information about uterine involution, risk of postpartum hemorrhage, and overall maternal well-being. Regular fundal assessments help nurses monitor the progress of recovery and detect any deviations from normal, enabling timely interventions to promote maternal health and prevent complications.
Question 2 of 5
A client is concerned that her breasts are engorged and uncomfortable. What is the nurse's explanation for this physiologic change?
Correct Answer: D
Rationale: The correct answer is D) Congestion of veins and lymphatic vessels. Engorgement in breastfeeding mothers occurs due to the increased blood flow to the breasts, leading to congestion of veins and lymphatic vessels. This causes swelling, tenderness, and discomfort in the breasts. Option A) Overproduction of colostrum is incorrect because engorgement is not due to colostrum production but rather to fluid accumulation and increased blood flow. Option B) Accumulation of milk in the lactiferous ducts and glands is incorrect as engorgement typically occurs before the milk production is fully established. Option C) Hyperplasia of mammary tissue is incorrect because engorgement is primarily a result of increased blood and fluid in the breast tissues, not due to increased tissue growth. Educationally, understanding the physiological changes in breast engorgement is crucial for nurses providing care to breastfeeding mothers. By knowing the correct explanation for this common issue, nurses can offer appropriate interventions and support to relieve discomfort and promote successful breastfeeding.
Question 3 of 5
The nurse should be cognizant of which postpartum physiologic alteration?
Correct Answer: B
Rationale: In maternal newborn nursing, understanding postpartum physiologic alterations is crucial for providing optimal care to mothers. The correct answer is option B: Respiratory function returns to nonpregnant levels by 6 to 8 weeks after childbirth. This is an essential physiological change to monitor as it impacts the overall health and well-being of the mother. Option A is incorrect because cardiac output, pulse rate, and stroke volume may take longer than 48 hours to return to prepregnancy normal values. Option C is incorrect as a lowered white blood cell count after pregnancy does not typically lead to false-positive results on tests for infections. Option D is incorrect because although a hypercoagulable state is present postpartum, it does not necessarily protect the mother from thromboembolism, especially after a cesarean birth. Educationally, understanding these postpartum physiologic alterations prepares nurses to recognize and respond to potential complications in the postpartum period. Monitoring respiratory function is vital for detecting any abnormalities early on and ensuring the mother's well-being. Nurses need to be knowledgeable about these changes to provide evidence-based care and promote positive outcomes for both the mother and newborn.
Question 4 of 5
The nurse is providing instruction to the newly delivered client regarding postbirth uterine and vaginal discharge, called lochiWhich statement is the most appropriate?
Correct Answer: D
Rationale: The correct answer is D: "It should smell like normal menstrual flow unless an infection is present." This statement is most appropriate because it accurately reflects the expected odor of lochia, which is typically described as similar to a normal menstrual flow unless an infection is present. This information is crucial for the client to monitor their postpartum recovery for signs of infection, such as foul-smelling discharge. Option A is incorrect because lochia is typically heavier and more prolonged than a light menstrual period in the immediate postpartum period. Option B is incorrect as the amount of lochia is not necessarily greater after cesarean births compared to vaginal deliveries. Option C is incorrect as while ambulation and breastfeeding can help with uterine involution and reduce bleeding, they do not directly impact the amount of lochia. In an educational context, understanding postpartum discharge is essential for maternal newborn nurses to educate clients on normal postpartum changes, signs of complications, and the importance of seeking medical attention if any abnormalities are noted. Proper education on lochia can empower clients to monitor their health effectively during the postpartum period.
Question 5 of 5
Which documentation on a woman's chart on postpartum day 14 indicates a normal involution process?
Correct Answer: C
Rationale: In maternal newborn nursing, understanding the normal postpartum involution process is crucial for providing appropriate care. Option C, "Fundus below the symphysis and nonpalpable," indicates a normal involution process on postpartum day 14. This finding suggests that the uterus has involuted to its pre-pregnancy size and is descending back into the pelvis, which is expected at this stage postpartum. Options A, B, and D are incorrect. Option A, "Moderate bright red lochial flow," may indicate a normal lochial discharge, but it does not specifically reflect the involution process of the uterus. Option B, "Breasts firm and tender," pertains to breast changes related to lactation and not uterine involution. Option D, "Episiotomy slightly red and puffy," focuses on the healing process of an episiotomy site and is not directly related to uterine involution. Educationally, it is essential for nurses to accurately interpret and document postpartum assessments to monitor the mother's recovery effectively. Understanding the significance of specific findings, such as the position of the fundus, helps in identifying deviations from normal and initiating timely interventions. This knowledge ensures optimal postpartum care and promotes maternal well-being.