ATI RN
Postpartum Hormonal Changes Questions
Question 1 of 5
Which clinical finding should the nurse suspect if the fundus is palpated on the right side of the abdomen above the expected level?
Correct Answer: A
Rationale: The correct answer is A, a distended bladder. When the fundus is palpated on the right side above the expected level, it indicates that the bladder is full and pushing the uterus upward and to the right. This can interfere with the normal descent of the uterus during involution, leading to the fundus being higher than expected. Choice B, normal involution, is incorrect as it does not explain the fundus being palpated above the expected level. Choice C, lying on her right side too long, is incorrect as body position does not typically result in the fundus being displaced. Choice D, stretched ligaments that are unable to support the uterus, is incorrect as stretched ligaments would not cause the fundus to be palpated above the expected level; rather, it would lead to a lower position of the uterus.
Question 2 of 5
The nurse has completed a postpartum assessment on a patient who delivered 1 hour ago. Which amount of lochia consists of a moderate amount?
Correct Answer: B
Rationale: The correct answer is B (10 to 15 cm (4- to 6-inch) stain on the peripad) because a moderate amount of lochia typically indicates a blood stain of 10 to 15 cm within 1 hour postpartum. This amount of lochia signifies a normal postpartum bleeding pattern. Incorrect answers: A: Saturated peripad indicates a heavy amount of lochia, not moderate. C: 2.5 to 10 cm (1- to 4-inch) stain on the peripad is considered light, not moderate. D: Less than a 1-inch stain on the peripad is minimal lochia, not moderate.
Question 3 of 5
The nurse is caring for a postpartum patient who delivered by the vaginal route 12 hours ago. Which assessment finding should the nurse report to the health care provider?
Correct Answer: A
Rationale: Correct Answer: A - Pulse rate of 50 Rationale: 1. A normal postpartum pulse rate is 60-100 bpm. 2. A pulse rate of 50 is below normal range, indicating potential bradycardia. 3. Bradycardia can be a sign of postpartum hemorrhage or other complications. 4. Reporting this finding promptly can help in early intervention. Summary: B: A temperature of 38C (100.4F) could indicate infection but is within normal postpartum range. C: A firm fundus with excessive lochia may indicate uterine atony, but is not as urgent as bradycardia. D: Feeling lightheaded when changing positions is common postpartum but not as concerning as a low pulse rate.
Question 4 of 5
When assessing the A of the acronym REEDA, the nurse should evaluate the
Correct Answer: C
Rationale: The correct answer is C. When assessing the A of REEDA (Redness, Edema, Ecchymosis, Discharge, and Approximation) in wound assessment, nurses should evaluate the edges of the episiotomy. This is important to ensure proper healing and closure of the incision site. Evaluating skin color (A) is important for overall wound assessment but not specifically for the edges of the episiotomy. Edema (B) refers to swelling, which is important to monitor but not specific to the edges of the episiotomy. Checking the episiotomy for discharge (D) is relevant for the "D" component of REEDA but not for the "A" component, which specifically focuses on the edges of the incision.
Question 5 of 5
The nurse is providing care to a patient who delivered a 3525-g infant 14 hours ago. The nurse palpates the fundus of the uterus as firm and at the umbilicus. What is the nurse’s priority action related to this finding?
Correct Answer: D
Rationale: The correct answer is D: Document the finding in the patient’s chart. The fundus being firm and at the umbilicus indicates normal involution after delivery. Documenting this finding is essential for accurate assessment and continuity of care. Informing the health care provider (choice A) is not necessary as the finding is normal. Encouraging the patient to urinate (choice B) is important for postpartum care but not the priority in this situation. Massaging the uterus to expel clots (choice C) is not indicated as the fundus is already firm, indicating proper contraction.