ATI RN
Postpartum Body Changes Questions
Question 1 of 5
If the rubella vaccine is indicated for a postpartum patient, which instructions should be provided?
Correct Answer: D
Rationale: The correct answer is D because the rubella vaccine contains live virus and poses a risk to the fetus if the patient becomes pregnant within 28 days of receiving the vaccine. Providing instructions about the risks of pregnancy after vaccination is crucial to prevent potential harm to the fetus. A: Incorrect - Specific instructions are necessary due to the live virus in the vaccine. B: Incorrect - Drinking fluids does not address the specific risks associated with pregnancy after vaccination. C: Incorrect - Stopping breastfeeding is not necessary after receiving the rubella vaccine.
Question 2 of 5
The postpartum nurse has completed discharge teaching for a patient being discharged after an uncomplicated vaginal birth. Which statement by the patient indicates that further teaching is necessary?
Correct Answer: B
Rationale: The correct answer is B because the patient's statement about not needing birth control if breastfeeding and supplementing with formula is incorrect. Breastfeeding is not a reliable form of birth control and additional contraception is necessary to prevent unintended pregnancy. Explanation: 1. Breastfeeding alone is not a foolproof method of contraception. 2. The combination of breastfeeding and formula feeding does not guarantee contraception. 3. Lactational amenorrhea method (LAM) is only effective if specific criteria are met. 4. The patient's misconception about not needing birth control while breastfeeding and supplementing with formula puts her at risk of unintended pregnancy. Summary: A: Correct statement about the timing of bowel movements postpartum. C: Incorrect statement about the normal pattern of bowel elimination postpartum. D: Correct statement about the need for birth control if not breastfeeding.
Question 3 of 5
To facilitate adequate urinary elimination during the postpartum period, the nurse should incorporate which intervention into the plan of care?
Correct Answer: D
Rationale: The correct answer is D, teaching the patient to perform pelvic floor exercises to combat potential stress incontinence. This intervention strengthens pelvic floor muscles, aiding in bladder control postpartum. Choice A is incorrect as carbonated beverages can irritate the bladder. Choice B is incorrect as postpartum diuresis increases fluid loss, increasing the risk of dehydration. Choice C is incorrect as limiting fluid intake can lead to dehydration and hinder urinary elimination.
Question 4 of 5
Which assessment finding 24 hours after vaginal birth would indicate a need for further intervention?
Correct Answer: B
Rationale: The correct answer is B because a saturated pad over a 2-hour period 24 hours after vaginal birth could indicate postpartum hemorrhage, a serious complication requiring immediate intervention. Excessive bleeding can lead to hypovolemic shock and endanger the mother's life. Monitoring and managing postpartum bleeding is crucial to prevent complications. A: Pain level of 5 is subjective and may vary among individuals. It does not necessarily indicate a need for immediate intervention. C: Urinary output of 500 mL in one voiding is within the normal range for postpartum women and does not suggest an immediate need for intervention. D: Uterine fundus 2 cm above the umbilicus is within the expected range for 24 hours postpartum and does not indicate a need for immediate intervention.
Question 5 of 5
The nurse is providing care to a patient 2 hours after a cesarean birth. In the hand-off report, he 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 correct answer is C: Contact the health care provider. This is the priority action because the sudden increase in lochia flow after breastfeeding could indicate postpartum hemorrhage, which is a serious complication that requires immediate medical attention. Contacting the healthcare provider will allow for prompt assessment and intervention. A: Weigh the peripad - This is not the priority action as assessing the amount of blood loss is important, but contacting the healthcare provider for further assessment and intervention takes precedence. B: Replace the peripad - While maintaining cleanliness and hygiene is important, addressing the potential postpartum hemorrhage is the priority. D: Document the finding in the patient’s chart - Documentation is necessary but should come after the immediate concern of postpartum hemorrhage is addressed.