ATI RN
Postpartum Body Changes Questions
Question 1 of 5
A woman who wishes to breastfeed advises the nurse that she had a breast reduction one year earlier. Which of the following responses by the nurse is appropriate?
Correct Answer: C
Rationale: The correct answer to the question is option C: "Monitor the baby's daily weights for excessive weight loss." This response is appropriate because it focuses on proactive monitoring of the baby's weight to ensure adequate nutrition intake, which is a crucial aspect of breastfeeding support, especially in cases where there may be challenges such as a history of breast reduction surgery. Option A is incorrect because it provides a definitive and discouraging statement without exploring potential solutions or supportive measures. It is essential in nursing practice to offer guidance and support rather than shutting down options for the patient. Option B is incorrect as examining the incision site does not directly address the immediate concern of breastfeeding success. While understanding the anatomy may be helpful, it is not the most pressing issue at hand. Option D is incorrect as it downplays the potential impact of breast reduction surgery on milk transfer. While it is true that surgery may not always prevent breastfeeding, it is important to acknowledge the potential challenges and take proactive measures to support successful breastfeeding. In an educational context, it is crucial for nurses to approach breastfeeding support holistically, considering individual circumstances and potential barriers. By emphasizing monitoring the baby's weight, the nurse can ensure early detection of any issues and provide timely interventions to support successful breastfeeding despite the woman's history of breast reduction surgery.
Question 2 of 5
The nurse is discharging five Rh-negative clients from the maternity unit. The nurse knows that the teaching was successful when the client who had which of the following deliveries asks why she must receive a RhoGAM injection? Select one that doesn't apply
Correct Answer: D
Rationale: The correct answer is D) Birth of Rh-negative twins at 35 weeks' gestation. In this scenario, the client delivered Rh-negative twins, which means there is no risk of Rh incompatibility as both babies lack the Rh antigen. Therefore, there is no need for RhoGAM injection in this situation. Option A) Abortion at 10 weeks' gestation: In an abortion at 10 weeks' gestation, there is a risk of fetal-maternal hemorrhage, leading to the exposure of the Rh antigen to an Rh-negative mother, necessitating RhoGAM administration. Option B) Amniocentesis at 16 weeks' gestation: Amniocentesis can lead to the mixing of fetal and maternal blood, increasing the risk of sensitization in an Rh-negative mother. RhoGAM is required in this situation to prevent Rh sensitization. Option C) Fetal demise at 24 weeks' gestation: In cases of fetal demise, there is a potential for fetal-maternal hemorrhage, exposing the mother to the Rh antigen. RhoGAM is administered to prevent Rh sensitization in this scenario. Educational context: Understanding the indications for RhoGAM administration in Rh-negative mothers is crucial in preventing Rh sensitization and subsequent hemolytic disease of the newborn in future pregnancies. Nurses must educate clients on the importance of RhoGAM injections to ensure the best outcomes for both current and future pregnancies.
Question 3 of 5
A woman, 26 weeks' gestation, has just delivered a fetal demise. Which of the following nursing actions is appropriate at this time?
Correct Answer: B
Rationale: The correct nursing action in this scenario is option B, to dress the baby in a tee shirt and swaddle the baby in a receiving blanket. This action is appropriate because it allows the mother to spend time with her deceased baby, providing her with the opportunity for closure, bonding, and the chance to say goodbye. It respects the mother's emotional needs and supports the grieving process by acknowledging the baby as a significant part of her life and pregnancy. Option A is incorrect because it minimizes the mother's current loss and grief by redirecting her focus to a future pregnancy, which may invalidate her feelings of loss and sadness. It overlooks the immediate emotional needs of the mother. Option C is inappropriate as it suggests medicating the mother without assessing her emotional state or providing emotional support. Sedation should not be the first-line intervention for a bereaved mother. Option D is also incorrect as it disregards the mother's right to spend time with her deceased baby and denies her the opportunity for closure and grieving. In an educational context, it is crucial for nurses to understand the significance of supporting mothers who experience perinatal loss. Providing compassionate and sensitive care during such difficult times is essential for the emotional well-being of the mother. Nurses need to prioritize empathy, communication, and respect for the mother's choices and feelings in these situations.
Question 4 of 5
A client is 10 minutes postpartum from a forceps delivery of a 4,500-gram neonate with a cleft lip. The physician performed a right mediolateral episiotomy during the delivery. The client is at risk for each of the following nursing diagnoses. Which of the diagnoses is highest priority at this time?
Correct Answer: D
Rationale: In this scenario, the highest priority nursing diagnosis is "D) Pain." Postpartum women who have undergone a forceps delivery and an episiotomy are likely to experience significant pain and discomfort. Managing pain is crucial as it can affect the client's overall well-being, ability to ambulate, perform self-care activities, and establish bonding with the newborn. Option A, "Ineffective breastfeeding," may be a concern in the postpartum period, but addressing the client's pain takes precedence as unresolved pain can hinder successful breastfeeding. Option B, "Fluid volume deficit," is not the highest priority at this immediate postpartum stage unless there are specific indicators suggesting this issue. Option C, "Infection," is important to monitor for but does not take precedence over addressing the client's pain. Educationally, understanding the hierarchy of postpartum nursing care priorities is essential for providing safe and effective care to postpartum clients. Pain management is a fundamental aspect of care that can significantly impact the client's recovery and overall experience during the postpartum period. By prioritizing pain management, nurses can promote the client's comfort, mobility, and ability to engage in essential activities of daily living.
Question 5 of 5
A client is 36 hours post-cesarean section. Which of the following assessments would indicate that the client may have a paralytic ileus?
Correct Answer: D
Rationale: In this scenario, the correct answer is D) Absent bowel sounds. A paralytic ileus is a temporary paralysis of the bowel that can occur after abdominal surgery, including a cesarean section. Absent bowel sounds are a key indicator of a paralytic ileus because they suggest that peristalsis, the involuntary muscle contractions that move food through the digestive system, is not functioning properly. Option A) Abdominal striae are stretch marks on the skin and are not indicative of a paralytic ileus. Option B) Oliguria refers to decreased urine output and is not directly related to bowel function. Option C) Omphalocele is a congenital abdominal wall defect and is not a relevant assessment finding in this context. Educationally, understanding postpartum body changes, including potential complications like paralytic ileus, is crucial for healthcare providers caring for postpartum clients. Recognizing signs and symptoms early can help in prompt intervention and prevent complications. Nurses and midwives need to be skilled in assessing and managing postpartum women to ensure optimal recovery and well-being.