ATI RN
Complication Postpartum Questions
Question 1 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 2 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.
Question 3 of 5
What is one of the initial signs and symptoms of puerperal infection in the postpartum client?
Correct Answer: D
Rationale: One of the initial signs and symptoms of puerperal infection in the postpartum client is an elevated temperature. A temperature of 38° C (100.4° F) or higher on 2 successive days is indicative of an infection. This can be a key indicator for healthcare providers to suspect puerperal infection, also known as postpartum infection or postpartum sepsis. It is important to monitor postpartum clients closely for any signs of infection, especially in the immediate postpartum period. Prompt recognition and management of puerperal infection is crucial to prevent serious complications for the mother.
Question 4 of 5
A woman who has recently given birth complains of pain and tenderness in her leg. On physical examination, the nurse notices warmth and redness over an enlarged, hardened area. Which condition should the nurse suspect, and how will it be confirmed?
Correct Answer: C
Rationale: Pain and tenderness in the extremities, which show warmth, redness, and hardness, is likely thrombophlebitis. A Doppler ultrasound examination is a common noninvasive way to confirm the diagnosis. A diagnosis of DIC is made according to clinical findings and laboratory markers. With DIC, a physical examination will reveal symptoms that may include unusual bleeding, petechiae around a blood pressure cuff on the woman’s arm, and/or excessive bleeding from the site of a slight trauma such as a venipuncture site. Symptoms of vWD, a type of hemophilia, include recurrent bleeding episodes, prolonged bleeding time, and factor VIII deficiency. A risk for PPH exists with vWD but does not exhibit a warm or reddened area in an extremity. ITP is an autoimmune disorder in which the life span of antiplatelet antibodies is decreased. Increased bleeding time is a diagnostic finding, and the risk of postpartum uterine bleeding is increase
Question 5 of 5
Which condition is considered a medical emergency that requires immediate treatment?
Correct Answer: A
Rationale: Inversion of the uterus is considered a medical emergency that requires immediate treatment. It occurs when the uterus turns inside out and protrudes through the cervix, which can lead to severe hemorrhage and shock. Prompt intervention is crucial to restore the uterus to its normal position, control bleeding, and prevent further complications such as infection or tissue necrosis. Failure to address uterine inversion promptly can result in life-threatening consequences for the mother. In contrast, hypotonic uterus, ITP (Idiopathic Thrombocytopenic Purpura), and uterine atony, while serious conditions, do not typically constitute immediate emergencies that necessitate urgent intervention on the same time-critical scale as uterine inversion.