ATI RN
Complication Postpartum Questions
Question 1 of 5
The nurse is assessing the midline episiotomy on a postpartum client. Which of the following findings should the nurse expect to see?
Correct Answer: B
Rationale: In assessing a midline episiotomy on a postpartum client, the nurse should expect to see well-approximated edges (Option B). This indicates proper healing and closure of the incision site. Well-approximated edges suggest that the incision is healing as expected and reduces the risk of infection and other complications. Option A, moderate serosanguinous drainage, may be expected in the immediate postpartum period, but it is not a specific finding related to the assessment of the episiotomy incision site. Option C, an ecchymotic area distal to the episiotomy, suggests bruising, which is not a typical finding in a well-healing incision. Option D, an area of redness adjacent to the incision, could indicate inflammation or infection, which would be concerning and not expected in a healing episiotomy. Educationally, understanding the expected findings in assessing a postpartum episiotomy is crucial for nurses to provide appropriate care, monitor for complications, and intervene promptly if needed to promote optimal healing and recovery for postpartum clients.
Question 2 of 5
A nurse is assessing the fundus of a client during the immediate postpartum period. Which of the following actions indicates that the nurse is performing the skill correctly?
Correct Answer: B
Rationale: In postpartum care, assessing the fundus correctly is crucial to monitor uterine involution and prevent complications. Option B, where the nurse stabilizes the base of the uterus with the dependent hand, is the correct action. This technique helps accurately locate and evaluate the fundus, ensuring proper contraction and preventing excessive bleeding. Option A is incorrect because measuring fundal height with a paper centimeter tape is not the primary method of fundal assessment. Option C is incorrect as palpating the fundus with the fingertips alone may not provide enough support to accurately assess uterine tone. Option D is incorrect as a sterile vaginal exam is not necessary for fundal assessment and should not precede it in routine postpartum care. Educationally, understanding the correct technique for fundal assessment is essential for nurses caring for postpartum clients. Proper fundal assessment can help identify early signs of postpartum hemorrhage or other complications, allowing for timely intervention and improved patient outcomes.
Question 3 of 5
The nurse is assessing the laboratory report on a 2-day postpartum G1 P1001. The woman had a normal postpartum assessment this morning. Which of the following results should the nurse report to the primary health care provider?
Correct Answer: C
Rationale: In this scenario, the correct answer is option C) Hematocrit, 26%. This result indicates a low hematocrit level, which could suggest postpartum hemorrhage, a common complication after childbirth. Postpartum hemorrhage can be life-threatening and requires immediate medical attention. Reporting this result promptly can lead to timely intervention and prevent further complications for the mother. Option A) White blood cells, 12,500 cells/mm3, is within normal range and not indicative of a significant issue postpartum. Option B) Red blood cells, 4,500,000 cells/mm3, is also within normal limits and does not raise immediate concerns. Option D) Hemoglobin, 11 g/dL, though slightly lower than normal, is not as concerning as a low hematocrit level in the context of postpartum assessment. Educationally, understanding the significance of laboratory values in the postpartum period is crucial for nurses caring for postpartum women. Recognizing abnormal results and knowing when to escalate them to the primary healthcare provider is essential in providing safe and effective care to postpartum mothers. This knowledge can help prevent complications and improve outcomes for both the mother and the newborn.
Question 4 of 5
A client, 2 days postpartum from a spontaneous vaginal delivery, asks the nurse about postpartum exercises. Which of the following responses by the nurse is appropriate?
Correct Answer: D
Rationale: The correct answer is D) You can do some Kegel exercises today and then slowly increase your toning exercises over the next few weeks. This response is appropriate because Kegel exercises help strengthen the pelvic floor muscles, which can aid in postpartum recovery. Starting with Kegel exercises is safe and beneficial for postpartum women. Slowly increasing toning exercises over time is important to prevent injury and allow the body to heal properly. Option A is incorrect because waiting until the postpartum checkup may delay the initiation of beneficial exercises. Option B is not ideal as it restricts all exercises except Kegels, limiting the client's ability to gradually regain strength. Option C is incorrect as it suggests returning to the pre-pregnancy exercise schedule too soon, which can be harmful and may not align with the client's current physical capabilities. In an educational context, it is crucial for nurses to provide evidence-based recommendations to postpartum clients regarding exercise. Understanding the physiological changes postpartum and tailoring exercise recommendations to promote recovery and prevent complications is essential for promoting maternal well-being. Teaching clients safe and effective postpartum exercises empowers them to take an active role in their recovery process.
Question 5 of 5
The nurse palpates a distended bladder on a woman who delivered vaginally 2 hours earlier. The woman refuses to go to the bathroom, 'I really don 't need to go. ' Which of the following responses by the nurse is appropriate?
Correct Answer: B
Rationale: In this scenario, option B is the most appropriate response by the nurse. The nurse should encourage the woman to try to urinate despite her refusal, as a distended bladder postpartum can lead to complications such as urinary retention, which can further lead to bladder distention, UTIs, or even damage to the bladder. Encouraging the woman to try to urinate helps prevent these complications and promotes her overall well-being. Option A is incorrect as it dismisses the nurse's findings of a distended bladder and does not address the issue at hand. Option C is incorrect as it assumes numbness from local anesthesia, which is not relevant to the situation described. Option D is incorrect because catheterization should be a last resort and should only be done if the woman is unable to void on her own after other interventions have been attempted. From an educational standpoint, this scenario highlights the importance of assessing and addressing postpartum complications promptly to prevent further issues. It also emphasizes the role of the nurse in advocating for the patient's health and well-being, even in situations where the patient may be hesitant or resistant. Encouraging open communication and providing appropriate care are vital aspects of nursing practice in postpartum care.