ATI RN
Chimat Maternity Needs Assessment Questions
Question 1 of 5
One hour after delivery the nurse is unable to palpate the uterine fundus of a client who had an epidural and notes a large amount of lochia on the perineal pad. The nurse massages at the umbilicus and obtains current vital signs. Which intervention should the nurse implement next.
Correct Answer: C
Rationale: In this scenario, the correct intervention for the nurse to implement next is option C: palpating the suprapubic area for bladder distention. This is the most appropriate action because a distended bladder can displace the uterus and prevent proper contraction, leading to postpartum hemorrhage. By assessing for bladder distention, the nurse can address this potential issue promptly. Option A is incorrect because documenting the number of pad changes does not address the immediate concern of a potentially distended bladder impacting uterine contraction. Option B is not the priority as assessing bladder distention takes precedence over ensuring the client can void. Option D is also incorrect as increasing the rate of oxytocin infusion without addressing the bladder distention could exacerbate the issue. Educationally, this scenario highlights the importance of prompt assessment and intervention in postpartum care. Nurses need to prioritize interventions based on potential complications that could arise post-delivery to ensure the well-being of the mother and prevent complications such as postpartum hemorrhage. Understanding the physiological changes that occur in the immediate postpartum period is crucial for providing effective and timely care to maternity patients.
Question 2 of 5
A woman who delivered a 9-pound baby boy by cesarean section under spinal anesthesia is recovering in the post anesthesia care unit. Her fundus is firm, at the umbilicus, and a continuous trickle of bright red blood with no clots from the vagina is observed by the nurse. Which actions should the nurse implemented.
Correct Answer: B
Rationale: In this scenario, the correct action for the nurse to take is to assess the woman's blood pressure (Option B). This is because the woman delivered a large baby via cesarean section, which puts her at higher risk for postpartum hemorrhage. The presence of bright red blood with no clots indicates active bleeding, and assessing her blood pressure can help determine if she is experiencing hypovolemic shock, a serious complication of postpartum hemorrhage. Prompt assessment and intervention are crucial in preventing further complications. Massage the fundus (Option A) is generally done to help the uterus contract and prevent excessive bleeding, but in this case, the fundus is already firm at the umbilicus, so massaging it may not be necessary and could even potentially cause discomfort. Applying an ice pack to the perineum (Option C) is commonly done for perineal pain and swelling after vaginal delivery, but it is not the priority in this situation where the focus should be on assessing and managing postpartum hemorrhage. Letting the infant breastfeed (Option D) is important for bonding and initiating breastfeeding, but it is not the most urgent action to take in this situation where the priority is to assess and manage potential postpartum hemorrhage. Educationally, this scenario highlights the importance of recognizing signs of postpartum hemorrhage and the need for prompt assessment and intervention in such situations to ensure the well-being of the mother. It emphasizes the significance of prioritizing actions based on the patient's condition and potential complications.
Question 3 of 5
A new mother, who is a lacto-ovo vegetarian, plans to breastfeed her infant. What information should the nurse provide prior to discharge.
Correct Answer: C
Rationale: In this scenario, the correct answer is C) Continue prenatal vitamins with B12 while breastfeeding. This option is correct because as a lacto-ovo vegetarian, the mother may have an increased risk of vitamin B12 deficiency due to the absence of animal products in her diet. Continuing prenatal vitamins with B12 while breastfeeding ensures that both the mother and the infant receive an adequate amount of this essential nutrient crucial for neurological development. Option A) Avoid using lanolin-based nipple cream or ointment is incorrect as it does not directly address the nutritional needs of the mother and the infant. Option B) Offering iron-fortified supplemental formula daily is unnecessary if the mother is able to maintain a balanced diet that meets her and her infant's nutritional needs through breastfeeding. Option D) Weigh the baby weekly to evaluate the newborn's growth is important but not directly related to the specific nutritional guidance needed for a lacto-ovo vegetarian mother. Educationally, it is crucial for healthcare providers to understand the unique dietary requirements of different populations, such as lacto-ovo vegetarians, and to provide tailored guidance to support optimal health outcomes for both the mother and the infant. By explaining the rationale behind the correct answer, nurses can empower mothers to make informed decisions regarding their diet and breastfeeding practices.
Question 4 of 5
A client at 38-weeks gestation complaints of severe abdominal pain. Upon the nurse notes that the abdomen is rigid.
Correct Answer: C
Rationale: In this scenario, the correct answer is C) Abruptio placenta. This condition involves the premature separation of the placenta from the uterine wall before delivery, leading to severe abdominal pain and a rigid abdomen due to internal bleeding and clot formation behind the placenta. Option A) Placenta previa is characterized by painless vaginal bleeding in the third trimester, not severe abdominal pain and rigidity. Option B) Oligohydramnios refers to low levels of amniotic fluid and is not typically associated with severe abdominal pain or rigidity. Option D) Chorioamnionitis is an infection of the fetal membranes and amniotic fluid, presenting with fever, uterine tenderness, and foul-smelling amniotic fluid, rather than severe abdominal pain and rigidity. Educationally, understanding these differential diagnoses is crucial for nursing students or healthcare providers working in maternity care to accurately assess and manage pregnant clients experiencing abdominal pain. Recognizing the signs and symptoms of abruptio placenta is vital for prompt intervention to ensure the well-being of both the mother and the fetus.
Question 5 of 5
The nurse is performing a newborn assessment. Which symptoms if present in newborn, would indicate respiratory distress?
Correct Answer: C
Rationale: In newborn assessment, recognizing signs of respiratory distress is crucial for prompt intervention. Option C, "Flaring of the nares," is the correct answer indicating respiratory distress in a newborn. Nasal flaring is a common sign of increased work of breathing and inadequate oxygenation. It suggests the baby is struggling to get enough oxygen. Option A, "Abdominal breathing with synchronous chest movement," is incorrect as it describes a normal breathing pattern in newborns due to their immature respiratory system. Option B, "Shallow and irregular respirations," while abnormal, do not specifically indicate respiratory distress. Option D, "Respiratory rate of 50 breaths per minute," is within the normal range for a newborn. It is important to educate nurses that isolated respiratory rate alone may not always indicate distress; it must be interpreted in conjunction with other signs like nasal flaring, grunting, retracting, or cyanosis. Educationally, understanding these signs equips nurses to identify respiratory distress early, intervene promptly, and prevent potential complications in newborns. It is crucial for nurses working in maternity settings to be adept at recognizing these signs to ensure the well-being of neonates.