ATI RN
Postpartum Body Changes Questions
Question 1 of 5
To assess fundal contraction 6 hours after cesarean birth, which technique should the nurse utilize?
Correct Answer: D
Rationale: The correct answer is D. Gently palpating the fundus is the appropriate technique after cesarean birth to assess fundal contraction. This technique is recommended to prevent causing discomfort or dislodging the uterus. Assessing lochial flow (A) does not directly evaluate fundal contraction. Palpating forcefully through the abdominal dressing (B) can be painful and may not provide an accurate assessment. Placing hands on both sides of the abdomen and pressing downward (C) is not a recommended technique as it can potentially cause uterine displacement.
Question 2 of 5
To facilitate adequate urinary elimination during the postpartum period, the nurse should incorporate which intervention into the plan of care?
Correct Answer: D
Rationale: The correct answer is D, teaching the patient to perform pelvic floor exercises to combat potential stress incontinence. This intervention strengthens pelvic floor muscles, aiding in bladder control postpartum. Choice A is incorrect as carbonated beverages can irritate the bladder. Choice B is incorrect as postpartum diuresis increases fluid loss, increasing the risk of dehydration. Choice C is incorrect as limiting fluid intake can lead to dehydration and hinder urinary elimination.
Question 3 of 5
Which assessment finding 24 hours after vaginal birth would indicate a need for further intervention?
Correct Answer: B
Rationale: The correct answer is B because a saturated pad over a 2-hour period 24 hours after vaginal birth could indicate postpartum hemorrhage, a serious complication requiring immediate intervention. Excessive bleeding can lead to hypovolemic shock and endanger the mother's life. Monitoring and managing postpartum bleeding is crucial to prevent complications. A: Pain level of 5 is subjective and may vary among individuals. It does not necessarily indicate a need for immediate intervention. C: Urinary output of 500 mL in one voiding is within the normal range for postpartum women and does not suggest an immediate need for intervention. D: Uterine fundus 2 cm above the umbilicus is within the expected range for 24 hours postpartum and does not indicate a need for immediate intervention.
Question 4 of 5
The nurse is providing care to a patient 2 hours after a cesarean birth. In the hand-off report, he preceding nurse indicated that the patient’s lochia was scant rubra. On initial assessment, the oncoming nurse notes the patient’s peripad is saturated with lochia rubra immediately after breastfeeding her infant. What is the nurse’s priority action with this finding?
Correct Answer: C
Rationale: The correct answer is C: Contact the health care provider. This is the priority action because the sudden increase in lochia flow after breastfeeding could indicate postpartum hemorrhage, which is a serious complication that requires immediate medical attention. Contacting the healthcare provider will allow for prompt assessment and intervention. A: Weigh the peripad - This is not the priority action as assessing the amount of blood loss is important, but contacting the healthcare provider for further assessment and intervention takes precedence. B: Replace the peripad - While maintaining cleanliness and hygiene is important, addressing the potential postpartum hemorrhage is the priority. D: Document the finding in the patient’s chart - Documentation is necessary but should come after the immediate concern of postpartum hemorrhage is addressed.
Question 5 of 5
Which description best explains the term reciprocal attachment behavior?
Correct Answer: B
Rationale: The correct answer is B because reciprocal attachment behavior refers to the mutual and positive interactions between infants and their caregivers during the attachment process. This behavior involves the infant responding to the caregiver's actions with positive feedback, such as smiles, cooing, and seeking physical contact. This interaction strengthens the bond between the infant and caregiver. Choice A is incorrect because it describes the infant's behavior during a specific stage (quiet alert stage) but does not capture the reciprocal nature of attachment behavior. Choice C is incorrect because reciprocal attachment behavior is not unidirectional and does not solely depend on eye contact. Choice D is incorrect because reciprocal attachment behavior is not about eliciting specific feelings from the parents but rather about building a strong, mutual bond between the infant and caregiver.