ATI RN
Respiratory Pediatric Nursing Questions
Question 1 of 5
If the patient's white blood cell (WBC) count is 25,000/mm³ on her second postpartum day, which action should the nurse take?
Correct Answer: A
Rationale: An increase in WBC count to 25,000/mm³ during the postpartum period is considered normal and not a sign of infection. The nurse should document the finding. There is no reason to alert the health care provider. Antibiotics are not needed because the elevated WBCs are caused by the stress of labor and not an infectious process. There is no need for reassessment as it is expected for the WBCs to be elevated.
Question 2 of 5
The nurse is providing care to a patient 2 hours after a cesarean birth. In the hand-off report, the preceding nurse indicated that the patient's lochia was scant rubra. On initial assessment, the oncoming nurse notes the patient's peripad is saturated with lochia rubra immediately after breastfeeding her infant. What is the nurse's priority action with this finding?
Correct Answer: C
Rationale: The lochia of the cesarean birth mother will go through the same phases as that of the woman who had a vaginal birth; however, the amount will be reduced. The finding of a saturated pad is abnormal, even after breastfeeding, and an indication of hemorrhage. The health care provider needs to be notified immediately. Weighing the peripad will give an estimation of the blood loss; but, this assessment can result in a delay of care. Replacing the peripad and documentation of the findings are appropriate when the data are within normal limits.
Question 3 of 5
The nurse is providing care to a patient 2 hours after a cesarean birth. In the hand-off report, the preceding nurse indicated that the patient's lochia was scant rubra. On initial assessment, the oncoming nurse notes the patient's peripad is saturated with lochia rubra immediately after breastfeeding her infant. What is the nurse's priority action with this finding?
Correct Answer: C
Rationale: Saturated peripad with lochia rubra after cesarean birth indicates abnormal bleeding and potential hemorrhage. The nurse's priority action should be to contact the health care provider immediately for further assessment and intervention. Weighing the peripad can provide an estimation of blood loss but may cause a delay in care. Replacing the peripad and documenting the finding are appropriate actions but not the priority when facing potential hemorrhage.
Question 4 of 5
A postpartum patient would be at increased risk for postpartum hemorrhage if she delivered a(n)
Correct Answer: B
Rationale: The correct answer is B because a rapid labor and birth may cause exhaustion of the uterine muscle and prevent contraction, increasing the risk of postpartum hemorrhage. Delivering a 5lb, 2oz infant with outlet forceps would put the patient at risk for lacerations due to forceps use. A 7lb infant after an 8 hour labor is a normal progression, and an 8lb infant after a 12 hour labor is also a normal progression.
Question 5 of 5
Nursing measures that help prevent postpartum urinary tract infection include
Correct Answer: A
Rationale: Adequate fluid intake prevents urinary stasis, dilutes urine, and flushes out waste products, reducing the risk of urinary tract infections. Early ambulation, not bed rest, is encouraged postpartum. Acidifying drinks like cranberry juice can also help prevent infections. Delaying voiding can lead to urinary stasis and increase the risk of infection.