ATI RN
Complications of Postpartum Questions
Question 1 of 5
The nurse continues to monitor a patient after a vaginal delivery with an estimated blood loss of 1,000 mL. Which assessment finding does the nurse recognize as requiring Stage 3 hemorrhage protocol?
Correct Answer: C
Rationale: The correct answer is C: Development of abnormal vital signs. Stage 3 hemorrhage protocol is initiated when vital signs such as tachycardia, hypotension, and tachypnea are present, indicating severe blood loss. Increased patient restlessness (choice A) and manifestations of severe pain (choice B) are important but do not specifically indicate Stage 3 hemorrhage. Patient requesting water for extreme thirst (choice D) is not a typical sign of hemorrhage. Abnormal vital signs are the key indicator for initiating Stage 3 hemorrhage protocol as they reflect the body's compensatory mechanisms in response to significant blood loss.
Question 2 of 5
The nurse is providing postpartum care for a patient after a vaginal delivery. Which assessment finding causes the nurse to suspect endometritis from beta-hemolytic streptococcus?
Correct Answer: D
Rationale: The correct answer is D, an elevated temperature greater than 100.4°F. Endometritis, an infection of the uterine lining, commonly caused by beta-hemolytic streptococcus, often presents with a fever. This is a key sign of infection, indicating the presence of an inflammatory process. The other choices are incorrect because: A: Scant amount of odorless lochia is indicative of normal postpartum discharge, not necessarily endometritis. B: Headache, malaise, and chills are non-specific symptoms that could be present in various conditions, not specific to endometritis. C: Pain or discomfort in the midline lower abdomen could be related to postpartum uterine contractions or other causes, but it is not a specific finding for endometritis.
Question 3 of 5
The nurse is preparing discharge teaching for a postpartum patient who exhibits signs and symptoms of an episiotomy infection and is on oral antibiotic therapy. Which discharge teaching will the nurse provide regarding pain management?
Correct Answer: B
Rationale: The correct answer is B: Information applicable to medication therapy. The rationale is that proper pain management is crucial for patient comfort and healing. The nurse should educate the patient on the importance of taking the prescribed pain medication as directed to manage pain effectively. This includes information on dosage, frequency, and potential side effects. Hot packs (Choice A) may not be recommended for an infected episiotomy as heat can exacerbate the infection. Ambulation (Choice C) is important for circulation, but it may not directly address pain management. Medicating for pain above level 4 (Choice D) is vague and does not provide specific guidance on when to take pain medication.
Question 4 of 5
The nurse is providing care for a patient who is 1 day postpartum and exhibiting symptoms of postpartum psychosis. Which medical management does the nurse expect for this patient?
Correct Answer: C
Rationale: Step 1: Postpartum psychosis is a psychiatric emergency requiring immediate intervention. Step 2: Immediate hospitalization in a psychiatric unit ensures safety and specialized care. Step 3: Hospitalization allows for close monitoring, medication management, and therapy. Step 4: Discharge to home or prescribed neonate visits are not appropriate due to the severity of symptoms in postpartum psychosis.
Question 5 of 5
The nurse is preparing a postpartum patient for discharge. For which reasons does the nurse instruct the patient to call the primary care provider? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Foul-smelling lochia. This indicates a possible infection in the uterus, which requires medical attention to prevent complications. Hot, red, painful breasts (B) may indicate mastitis, which also requires medical intervention. Mild headache (C) and not sleeping well (D) are common postpartum issues but do not typically require immediate medical attention. In summary, choices B, C, and D are incorrect because they are common postpartum symptoms that do not necessarily warrant contacting the primary care provider, unlike foul-smelling lochia (A), which could indicate a serious issue.