ATI RN
Postpartum Body Changes Questions
Question 1 of 5
The nurse administers RhoGAM to a postpartum client. Which of the following is the goal of the medication?
Correct Answer: A
Rationale: RhoGAM is administered to a postpartum client who is Rh-negative to prevent the mother's immune system from producing antibodies against Rh-positive fetal blood cells, a condition known as Rh incompatibility. Option A, "Inhibit the mother's active immune response," is the correct answer because RhoGAM works by suppressing the mother's immune response to Rh-positive blood cells she may have been exposed to during pregnancy or delivery. Option B, "Aggressively destroy the Rh antibodies produced by the mother," is incorrect because RhoGAM does not destroy existing Rh antibodies but rather prevents their formation. Option C, "Prevent fetal cells from migrating throughout the mother's circulation," is incorrect as RhoGAM does not act on fetal cells but on the mother's immune system. Option D, "Change the maternal blood type to Rh-positive," is inaccurate as RhoGAM does not alter the mother's blood type. In an educational context, understanding the rationale behind administering RhoGAM is crucial for nurses caring for postpartum clients. By grasping the purpose of this medication, nurses can provide safe and effective care to prevent complications related to Rh incompatibility in future pregnancies. It also highlights the importance of maternal-fetal blood type compatibility and the role of immunoprophylaxis in preventing hemolytic disease of the newborn.
Question 2 of 5
A client, who had no prenatal care, delivers a 10-lb 10-oz baby boy whose serum glucose result 1 hour after delivery was 20 mg/dL. Based on these data, which of the following tests should the mother have at her 6-week postpartum checkup?
Correct Answer: A
Rationale: The correct answer is A) Glucose tolerance test. In this scenario, the mother's baby had a high birth weight and low serum glucose level, indicating a risk for gestational diabetes. Without prenatal care, there was no monitoring of the mother's blood glucose levels during pregnancy. Therefore, a glucose tolerance test at the 6-week postpartum checkup is crucial to assess the mother's glucose metabolism and screen for diabetes. Option B) Indirect Coombs' test is used to detect antibodies in the mother's blood that could attack the baby's red blood cells, which is unrelated to the presented scenario of glucose monitoring. Option C) Blood urea nitrogen (BUN) measures kidney function and is not directly related to the mother's risk of developing gestational diabetes. Option D) Complete blood count (CBC) assesses levels of different blood components and is not specific to monitoring glucose levels postpartum. Educationally, understanding the importance of postpartum monitoring for women who had high-risk pregnancies, like in this case with a large baby and low serum glucose levels, highlights the necessity of comprehensive care for both the mother and baby. Regular follow-up and appropriate tests are essential for early detection and management of potential health issues postpartum.
Question 3 of 5
A nurse is caring for the following four laboring patients. Which client should the nurse be prepared to monitor closely for signs of postpartum hemorrhage (PPH)? Select one that doesn't apply
Correct Answer: D
Rationale: In this scenario, option D is the correct answer. The nurse should be prepared to monitor client D closely for signs of postpartum hemorrhage (PPH) due to the risk factors associated with delivering a large-for-gestational-age baby at 42 weeks. Postpartum hemorrhage is more common in women who have delivered larger babies due to potential uterine atony or inability of the uterus to contract effectively after delivery. Additionally, the prolonged gestation increases the risk of uterine atony and subsequent PPH. Option A can be eliminated because delivering a fetal demise at 29 weeks does not typically increase the risk of PPH. Option B, a prolonged first stage of labor, may lead to exhaustion but is not a direct risk factor for PPH. Option C, a cesarean section for failure to progress, does not inherently increase the risk of PPH unless there are complications during or after the surgery. Educationally, understanding the risk factors for postpartum hemorrhage is crucial for nurses caring for laboring patients. By recognizing the factors that can contribute to PPH, nurses can provide appropriate monitoring, interventions, and support to prevent or manage this potentially life-threatening complication effectively.
Question 4 of 5
A home care nurse is visiting a breastfeeding client who is 2 weeks postdelivery of a 7-lb baby girl over a midline episiotomy. Which of the following findings should take priority?
Correct Answer: D
Rationale: In this scenario, the priority finding is option D) Client yells at the baby for crying. This behavior raises concerns about the client's mental and emotional well-being, as well as the potential for postpartum depression or other mental health issues. As a home care nurse, ensuring the safety and well-being of both the mother and baby is crucial. Option A) Lochia is serosa, while important, does not pose an immediate threat to the client or her baby's safety. Option B) Client cries throughout the visit may indicate emotional distress, but it is not as urgent as the potential risk of harm to the baby from the client yelling. Option C) Nipples are cracked is a common issue in breastfeeding mothers but does not take precedence over the safety of the baby in this situation. Educationally, this scenario highlights the importance of assessing not only physical but also mental health status in postpartum clients. It underscores the need for healthcare providers to be vigilant for signs of postpartum depression or other mental health concerns, as early intervention is key to ensuring the well-being of both the mother and baby. It also emphasizes the critical role of the nurse in providing holistic and comprehensive care to postpartum clients.
Question 5 of 5
A breastfeeding client is being seen in the emergency department with a hard, red, warm nodule in the upper outer quadrant of her left breast. Her vital signs are: T 104.6°F, P 100, R 20, and BP 110/60. She has a recent history of mastitis and is crying in pain. Which of the following nursing diagnoses is highest priority?
Correct Answer: B
Rationale: In this scenario, the highest priority nursing diagnosis is B) Infection. The client's presentation with a hard, red, warm nodule in the breast, elevated temperature, history of mastitis, and severe pain indicates a potential breast infection, which requires immediate attention to prevent further complications like abscess formation or sepsis. Option A) Ineffective breastfeeding is incorrect as the primary concern here is addressing the infection to ensure the client's health and safety. Option C) Ineffective individual coping may be a secondary concern once the infection is under control. Option D) Pain is important, but treating the underlying infection takes precedence. Educationally, it is crucial for nurses to prioritize nursing diagnoses based on the urgency of the client's condition. Understanding the signs and symptoms of infections like mastitis in breastfeeding clients is essential for early identification and intervention to prevent serious complications. Nurses must be prepared to act swiftly in cases of suspected infections to provide appropriate care and support to their clients.