ATI RN
Complications of Postpartum Questions
Question 1 of 5
The nurse is caring for a client who had a cesarean section under spinal anesthesia less than 2 hours ago. Which of the following nursing actions is appropriate at this time?
Correct Answer: C
Rationale: In this scenario, the appropriate nursing action is to have the client turn and deep breathe every 2 hours (Option C). This is crucial post-cesarean section under spinal anesthesia to prevent complications such as atelectasis and promote optimal lung expansion, preventing respiratory issues. Option A, elevating the head of the bed 60 degrees, is incorrect as it could increase the risk of hypotension due to the decreased venous return. Reporting the absence of bowel sounds to the physician (Option B) is not a priority at this early postoperative stage. Assessing for patellar hyperreflexia bilaterally (Option D) is not relevant in this immediate postoperative period and does not address the client's current needs. Educationally, it is essential for nurses to understand the specific postoperative care requirements for clients who have undergone cesarean sections under spinal anesthesia to promote optimal recovery and prevent complications. Encouraging turning and deep breathing helps maintain respiratory function and prevent postoperative respiratory issues.
Question 2 of 5
The nurse is caring for a client who had an emergency cesarean section, with her husband in attendance, the day before. The baby 's Apgar was 9/9. The woman and her partner had attended childbirth education classes and had anticipated having a water birth with family present. Which of the following comments by the nurse is appropriate?
Correct Answer: B
Rationale: The correct answer is B) "With all of your preparations, it must have been disappointing for you to have had a cesarean." This response demonstrates empathy and acknowledges the woman's feelings of disappointment and possibly loss of control over her birth experience. It validates her emotions and shows understanding of the situation she is facing. Option A) is inappropriate because it dismisses the woman's feelings and experience by implying that unexpected outcomes are normal and should be accepted without acknowledging her emotions. Option C) while acknowledging the baby's health, fails to address the woman's emotional state and could come across as minimizing her feelings about the birth experience. Option D) focuses on the presence of the husband but does not address the woman's feelings about the birth experience or her disappointment in not having the birth she had planned for. In an educational context, it is crucial for healthcare providers to practice empathy and active listening when communicating with patients, especially in sensitive situations like childbirth. Acknowledging and validating a patient's feelings can help build trust and improve the overall quality of care provided.
Question 3 of 5
The obstetrician has ordered that a post-op cesarean section client 's patient-controlled analgesia (PCA) be discontinued. Which of the following actions by the nurse is appropriate?
Correct Answer: A
Rationale: In this scenario, the appropriate action for the nurse to take is option A) Discard the remaining medication in the presence of another nurse. This choice is correct because it ensures proper disposal of the controlled substance, preventing misuse or diversion. Patient-controlled analgesia (PCA) should be discontinued as per the physician's orders to prevent overmedication or potential side effects. Option B) Recommend waiting until her pain level is zero to discontinue the medicine is incorrect as it does not align with best practice. Pain management should be individualized and based on the patient's needs, not solely on achieving a pain level of zero. Option C) Discontinuing the medication only after the analgesia is completely absorbed is incorrect as it does not address the need for immediate discontinuation as per the physician's order. Option D) Returning the unused portion of medication to the narcotics cabinet is incorrect as controlled substances should never be returned to the cabinet once dispensed to a patient, to prevent diversion and ensure accurate tracking of medication administration. Educationally, this question highlights the importance of following physician's orders accurately, proper disposal of controlled substances, and individualized pain management strategies in postpartum care. Nurses need to be vigilant in medication management to ensure patient safety and prevent medication errors.
Question 4 of 5
A client, 2 days postoperative from a cesarean section, complains to the nurse that she has yet to have a bowel movement since the surgery. Which of the following responses by the nurse would be appropriate at this time?
Correct Answer: B
Rationale: The correct answer is B) Two days is not that bad. Some patients go four days or longer without a movement. This response by the nurse is appropriate because it reassures the client that her situation is not uncommon and does not warrant immediate concern. Postoperative constipation is a common issue due to factors like reduced mobility, anesthesia effects, and opioid pain medications. Option A is incorrect because ordering an enema should not be the first line of action for postoperative constipation, especially without further assessment. Option C is incorrect as antibiotics through IV may contribute to constipation but are not the sole reason, and addressing constipation is more multifaceted. Option D is not the best response as focusing solely on fluids and exercise oversimplifies the issue of postoperative constipation which may require a more comprehensive approach. Educationally, it is crucial for nurses to understand the physiological factors contributing to postoperative constipation and the appropriate management strategies. Nurses should provide holistic care, including assessing bowel patterns, promoting early ambulation, adequate hydration, fiber intake, and considering stool softeners or laxatives as needed. It is important to educate clients on postoperative expectations and empower them to manage common complications effectively.
Question 5 of 5
A nurse is assessing a 1-day-postpartum woman who had her baby by cesarean section. Which of the following should the nurse report to the surgeon?
Correct Answer: D
Rationale: In this scenario, the correct answer is D) Pad saturation every 30 minutes. This finding indicates excessive postpartum bleeding, which is a critical complication that requires immediate attention. Post-cesarean section, monitoring for hemorrhage is crucial due to the risk of uterine atony or other causes of bleeding. Excessive bleeding can lead to hypovolemic shock and even be life-threatening for the mother. Option A) Fundus at the umbilicus is a normal finding in the immediate postpartum period. The fundus should be firm and midline to promote uterine involution. Nodular breasts (Option B) are also a normal postpartum finding related to milk production. A pulse rate of 60 bpm (Option C) is within the normal range for a postpartum woman and does not raise immediate concerns. Educationally, understanding the significance of postpartum complications and the importance of timely assessment and reporting is crucial for nurses caring for postpartum women. Recognizing abnormal findings and knowing when to escalate care is essential in preventing adverse outcomes for both the mother and the newborn. Regular education and training on postpartum complications and assessment skills are necessary for healthcare providers to deliver safe and effective care to postpartum women.