ATI RN
Complication Postpartum Questions
Question 1 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 2 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.
Question 3 of 5
The postpartum nurse notices that the last dose of IV Cefazolin is not running well. The patient’s IV site appears red, inflamed, and swollen. The patient states that the IV is tender and sore. What are the nurse’s next actions?
Correct Answer: C
Rationale: The correct answer is C: Remove the IV, restart it in a new location, and complete the antibiotic administration. This is the correct action because the patient's IV site is showing signs of infection (redness, inflammation, swelling, tenderness). By removing the IV, the nurse can prevent the spread of infection and restart the antibiotic infusion in a new, sterile site to ensure proper treatment. A: Flushing the IV with normal saline will not address the underlying issue of infection and may worsen the patient's condition. B: Putting the IV antibiotic on a pump for more accurate infusion does not address the fact that the current IV site is infected and needs to be removed. D: Allowing the IV to continue to drip slowly is not appropriate when the site is showing signs of infection.
Question 4 of 5
What is the most common reason for late postpartum hemorrhage (PPH)?
Correct Answer: A
Rationale: Late postpartum hemorrhage (PPH), defined as occurring between 24 hours and up to 12 weeks after delivery, is most commonly due to subinvolution of the uterus. This occurs when the uterus fails to return to its normal pre-pregnancy size. Subinvolution can be caused by retained products of conception, uterine infection, uterine anomalies, or inadequate contraction of the uterine muscles. When the uterus does not contract effectively, it is unable to compress the blood vessels at the site of the placental attachment, leading to persistent bleeding. Subinvolution of the uterus is an important cause of late PPH and requires prompt intervention to prevent excessive blood loss and its associated complications.
Question 5 of 5
The nurse suspects that her postpartum client is experiencing hemorrhagic shock. Which observation indicates or would confirm this diagnosis?
Correct Answer: D
Rationale: Hemorrhagic shock is characterized by inadequate tissue perfusion due to severe blood loss, leading to decreased circulating volume. The body's compensatory mechanisms kick in to maintain blood pressure, causing the peripheral blood vessels to constrict. This constriction can lead to cool, clammy, and pale skin as the body shunts blood away from the skin's surface to the vital organs. The skin may also feel cool to the touch due to reduced perfusion. This observation is significant in indicating hemorrhagic shock because it signifies the body's response to the insufficient circulating volume and the need to prioritize perfusion to essential organs.