ATI RN
Complication Postpartum Questions
Question 1 of 5
The nurse is performing an assessment of the uterus 30 minutes after a normal delivery and finds the fundus to be soft and boggy. IV Pitocin is infusing at 150 mL/hr. What is the priority nursing intervention?
Correct Answer: B
Rationale: The correct answer is B because a soft and boggy fundus after delivery indicates uterine atony, which can lead to postpartum hemorrhage. Performing external massage of the uterus will help stimulate contractions and firm up the fundus. Assessing for additional bleeding is crucial to monitor for hemorrhage. Updating the licensed provider is important for further management. Choice A is incorrect because simply increasing Pitocin without addressing the uterine atony may not resolve the issue. Choice C is incorrect as notifying the provider of increased blood loss is not the immediate priority; addressing the uterine atony is. Choice D is incorrect as assisting the patient to the bathroom does not address the soft and boggy fundus issue.
Question 2 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 3 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 4 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 5 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.