ATI RN
Complication Postpartum Questions
Question 1 of 5
During a home visit, the nurse assesses a client 2 weeks after delivery. Which of the following signs/symptoms should the nurse expect to see?
Correct Answer: B
Rationale: In the postpartum period, Lochia alba is the expected discharge 2 weeks after delivery. Lochia alba is the final stage of lochia, characterized by a yellowish-white discharge containing leukocytes, decidual tissue, and mucus. This discharge indicates normal healing of the uterine lining post-delivery. Diaphoresis, excessive sweating, is common in the immediate postpartum period as the body eliminates excess fluid accumulated during pregnancy. However, it typically decreases by 2 weeks postpartum. Cracked nipples are common breastfeeding complications but are not specifically expected at 2 weeks postpartum. Hypertension is not a typical sign of the postpartum period unless it is related to a pre-existing condition like chronic hypertension or preeclampsia. Educationally, understanding the expected physiological changes in the postpartum period is crucial for nurses to provide appropriate care and education to new mothers. Recognizing normal postpartum signs and symptoms helps in early identification of complications, promoting maternal well-being and preventing unnecessary anxiety.
Question 2 of 5
The nurse is caring for a postpartum client who experienced a second-degree perineal laceration at delivery 2 hours ago. Which of the following interventions should the nurse perform at this time?
Correct Answer: A
Rationale: The correct answer is A) Apply an ice pack to the perineum. This intervention is appropriate for a second-degree perineal laceration as it helps to reduce swelling, inflammation, and pain in the perineal area. The application of ice packs also promotes vasoconstriction, which can help in minimizing bleeding and promoting healing of the laceration. Option B) Advise the woman to use a sitz bath after every voiding is not the most appropriate intervention at this time because using a sitz bath may not be recommended immediately after delivery, especially in the case of a recent perineal laceration. Sitz baths are generally recommended after the initial postpartum period when the perineal area has started to heal. Option C) Advise the woman to sit on a pillow may provide some comfort but does not directly address the issue of managing the perineal laceration or promoting healing. Option D) Teach the woman to insert nothing into her rectum is a general postpartum instruction to prevent infection but does not specifically address the immediate care needed for a second-degree perineal laceration. In an educational context, it is essential for nurses to understand the appropriate interventions for postpartum complications like perineal lacerations to provide optimal care and promote the well-being of their patients. Proper knowledge and application of evidence-based practices in postpartum care can help prevent complications and support the healing process for new mothers.
Question 3 of 5
A woman is receiving patient-controlled analgesia (PCA) post -cesarean section. Which of the following must be included in the patient teaching?
Correct Answer: B
Rationale: In the context of postpartum care following a cesarean section, it is crucial to educate the patient on the proper use of patient-controlled analgesia (PCA). Option B, which states that the client should report any feelings of nausea or itching to the nurse, is the correct answer. This is important because nausea and itching can be side effects of the pain medication administered through PCA, and timely reporting can help prevent complications or the need for additional interventions. Option A is incorrect because monitoring how often the button is pressed is not as critical as recognizing and reporting side effects. Option C is incorrect as only the patient should control the PCA administration to ensure safe dosing. Option D is incorrect because it is the responsibility of the patient, not the family, to communicate any changes in symptoms or condition to the healthcare team. Educationally, this question highlights the importance of patient education in managing postoperative pain and the role of the healthcare team in supporting patients through effective communication and monitoring for potential complications in the postpartum period.
Question 4 of 5
A postoperative cesarean section woman is to receive morphine 4 mg q 3 -4 h subcutaneously for pain. The morphine is available on the unit in premeasured syringes 10 mg/1 mL. Each time the nurse administers the medication, how many milliliters (mL) of morphine will be wasted? Calculate to the nearest tenth.
Correct Answer: B
Rationale: The correct answer is B) 0.6 mL. To calculate the wastage, we first determine the total morphine used in 24 hours, which is 4 mg every 3-4 hours. If we assume the maximum frequency (every 3 hours), the patient would receive 6 doses in 24 hours (24 hours ÷ 3 hours = 8 doses, but the last dose is not fully utilized). Therefore, the total morphine used in 24 hours is 24 mg (4 mg/dose x 6 doses). Given that each syringe contains 10 mg/1 mL, the total volume of morphine needed in 24 hours is 2.4 mL (24 mg ÷ 10 mg/mL = 2.4 mL). However, since the syringes are premeasured and contain 1 mL each, there will be a wastage of 0.4 mL per dose. Therefore, for 6 doses in 24 hours, the total wastage will be 2.4 mL (0.4 mL/dose x 6 doses), which is equivalent to 0.6 mL when rounded to the nearest tenth. Educationally, understanding medication calculations is crucial for safe and effective nursing practice. Nurses must be able to accurately calculate dosages to prevent medication errors and ensure patient safety. This question highlights the importance of precise calculations in medication administration to minimize wastage and optimize patient care.
Question 5 of 5
A client is receiving an epidural infusion of a narcotic for pain relief after a cesarean section. The nurse would report to the anesthesiologist if which of the following were assessed?
Correct Answer: A
Rationale: In this scenario, the correct answer is option A) Respiratory rate 8 rpm. This is the most critical assessment finding that would require immediate reporting to the anesthesiologist. The administration of a narcotic via epidural infusion can lead to respiratory depression as a side effect, especially when higher doses are used. A respiratory rate of 8 rpm is dangerously low and could indicate impending respiratory failure, a potentially life-threatening complication that requires immediate intervention. Complaint of thirst (option B) is a common side effect of narcotic medications but is not as urgent or concerning as respiratory depression. Urinary output of 250 mL/hr (option C) is within normal limits and not directly related to the administration of a narcotic. Numbness of feet and ankles (option D) is a common side effect of epidural anesthesia and does not indicate a critical issue requiring immediate attention. Educationally, this question highlights the importance of monitoring patients receiving epidural narcotic infusions postpartum for potential complications, particularly respiratory depression. Nurses must be vigilant in assessing vital signs and responding promptly to any signs of respiratory distress to ensure patient safety.