ATI RN
Complication Postpartum Questions
Question 1 of 5
The nurse and provider estimate the blood loss at delivery to be 400 mL in the measuring drape; now when doing the initial perineal care, the nurse finds a large amount of blood underneath the patient. What action reflects safe and accurate nursing care?
Correct Answer: D
Rationale: The correct answer is D. Weighing the blood-soaked linens provides an accurate measurement of the additional blood loss, which is crucial for assessing the patient's condition accurately. Here's the rationale step-by-step: 1. Weighing the blood-soaked linens is an objective and precise method to quantify the additional blood loss. 2. This measurement helps to determine the total blood loss accurately, which is essential for assessing postpartum hemorrhage. 3. Providing this quantitative data to the provider enables them to make informed decisions about further interventions. 4. Estimating blood loss visually is subjective and can be inaccurate, leading to potential underestimation or overestimation. 5. Drawing hematocrit levels (choice C) may provide valuable information but does not directly address the immediate need to quantify the additional blood loss. 6. Encouraging the mother to report bleeding (choice B) is important for ongoing assessment but does not provide an objective measurement of the blood loss. In summary
Question 2 of 5
The nurse is caring for a postpartum woman and her 2-hour-old baby. The new mother has been preoccupied with breastfeeding and visitors, but suddenly she complains of dizziness and is light-headed. Which response by the nurse is appropriate?
Correct Answer: D
Rationale: The correct response is D because the new mother's complaint of dizziness and light-headedness could indicate postpartum hemorrhage, a common complication. Obtaining vital signs will help assess for signs of shock. Assessing fundal tone can determine if the uterus is contracting properly to prevent excessive bleeding. Observing for excessive lochia is important to monitor for increased bleeding. Choice A is incorrect because the symptoms are not solely due to dehydration or lack of calories. Choice B is incorrect as the nurse should assess the mother first before delegating care to family members. Choice C is incorrect as dizziness is not a common side effect of pain medication in the postpartum period.
Question 3 of 5
The nurse is caring for a woman who is 6 hours postpartum after a vaginal delivery. She has a history of labial varicose veins and is reporting perineal pain of 8 on a 10-point scale. What interventions should the nurse include in the plan of care?
Correct Answer: C
Rationale: The correct answer is C because it addresses the patient's specific issue of perineal pain related to her history of labial varicose veins. By assessing the perineum for a hematoma or inflamed varicosities, the nurse can identify the cause of the pain and provide appropriate treatment. Administering oral pain medication targets the source of discomfort. Choice A is incorrect because providing an inflatable donut ring may offer temporary relief but does not address the underlying cause of the pain. Administering oral pain medication alone may not be sufficient without assessing the perineum. Choice B is incorrect because dismissing the patient's pain as normal without further assessment can lead to overlooking potential complications. Assisting the patient to a side-lying position does not address the pain. Choice D is incorrect because administering stool softeners and encouraging fluids may be beneficial for postpartum care but does not directly address the patient's perineal pain related to varicose veins.
Question 4 of 5
Hemabate has been ordered for a postpartum patient who has uncontrolled bleeding and uterine atony. Which is the appropriate nursing action?
Correct Answer: C
Rationale: The correct answer is C. The rationale is as follows: 1. Hemabate is a medication used to treat postpartum hemorrhage due to uterine atony. 2. Checking the patient's record for a history of asthma is crucial as Hemabate can exacerbate asthma symptoms. 3. Asking the provider for an antidiarrheal medication is appropriate to manage potential side effects of Hemabate. 4. Checking vital signs for hypotension (Choice A) is important but not the immediate nursing action. 5. Checking blood glucose and increasing IV fluids (Choice B) are not directly related to the administration of Hemabate. 6. Checking for a history of hypothyroid and asking for anti-nausea medication (Choice D) is irrelevant to Hemabate administration.
Question 5 of 5
A breastfeeding patient who is 5 weeks postpartum calls the clinic and reports that she is achy all over, has a temperature of 100.2°F, and has pain and tenderness in her right breast. What is the nurse’s best response?
Correct Answer: A
Rationale: The correct answer is A because the patient's symptoms of achiness, fever, and pain in the breast are indicative of mastitis, a common breast infection in breastfeeding women. Prompt evaluation and treatment are necessary to prevent complications. Choice B is incorrect as engorgement typically occurs in the first few days postpartum, not at 5 weeks. Choice C is incorrect because stopping breastfeeding can worsen the infection and affect milk production. Choice D is incorrect as the symptoms described are more likely due to an infection rather than just sleep deprivation.