ATI RN
Nursing Interventions for Pediatric Respiratory Distress 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: In this scenario, the correct answer is A) Distended bladder. When the fundus is palpated on the right side of the abdomen above the expected level, it indicates that the bladder is full and pushing the uterus upwards and to the right. This finding is crucial to recognize in postpartum care as a distended bladder can lead to uterine displacement, increased risk of postpartum hemorrhage, and discomfort for the mother. Option B) Normal involution is incorrect because the fundus being palpated above the expected level is not indicative of the expected physiological process of the uterus returning to its pre-pregnancy size. Option C) Been lying on her right side too long is incorrect as it does not explain the physiological reason behind the fundus being palpated higher on the right side of the abdomen. Option D) Stretched ligaments that are unable to support the uterus is incorrect because this choice does not address the immediate concern of a distended bladder, which requires prompt intervention to prevent complications. For nursing students and healthcare professionals, understanding the assessment findings related to postpartum care, including fundal height and position, is essential for providing safe and effective care to postpartum mothers. Prompt recognition of a distended bladder can prevent complications and promote the well-being of both the mother and the newborn.
Question 2 of 5
During which stage of role attainment do the parents become acquainted with their baby and combine parenting activities with cues from the infant?
Correct Answer: A
Rationale: A major task of the formal stage of role attainment is getting acquainted with the infant. The informal stage begins once the parents have learned appropriate responses to their infant's cues. The personal stage is attained when parents feel a sense of harmony in their role. The anticipatory stage begins during the pregnancy when the parents choose a physician and attend childbirth classes.
Question 3 of 5
A postpartum patient calls the clinic and reports to the nurse feelings of fatigue, tearfulness, and anxiety. What is the nurse's most appropriate response at this time?
Correct Answer: D
Rationale: The correct answer is D because the nurse needs to differentiate between postpartum blues and more serious conditions like postpartum depression. By asking if the patient is able to care for her baby, the nurse is assessing the severity of the symptoms and determining if the patient needs further evaluation or support. This response shows a proactive approach to addressing the patient's concerns and ensuring proper care.
Question 4 of 5
Which nursing measure would be most appropriate to prevent thrombophlebitis in the recovery period following a cesarean birth?
Correct Answer: B
Rationale: The most appropriate nursing measure to prevent thrombophlebitis in the recovery period following a cesarean birth is option B) Assist the patient in performing leg exercises every 2 hours. Performing leg exercises helps promote circulation and prevents blood stasis, which is crucial in reducing the risk of thrombophlebitis. This intervention aids in maintaining venous return, preventing the formation of blood clots, and promoting overall vascular health. Additionally, leg exercises help prevent muscle atrophy and improve the patient's mobility and comfort during the recovery period. Options A, C, and D are incorrect for preventing thrombophlebitis. Limiting oral intake of fluids for the first 24 hours (Option A) does not directly address the risk of thrombophlebitis and may lead to dehydration, which can actually increase the risk of clot formation. While ambulating the patient (Option C) is important for preventing complications post-cesarean, it may not be as effective in preventing thrombophlebitis as targeted leg exercises. Rolling a bath blanket behind the patient's knees (Option D) may provide comfort but does not address the underlying issue of promoting circulation and preventing clot formation in the same way that leg exercises do. In an educational context, it is crucial for nursing students to understand the rationale behind preventive measures for postoperative complications like thrombophlebitis. By grasping the importance of interventions such as leg exercises, students can provide evidence-based care to promote optimal patient outcomes and prevent potentially serious complications.
Question 5 of 5
Following a difficult vaginal birth of a singleton pregnancy, the patient starts bleeding heavily. Clots are expressed and a Foley catheter is inserted to empty the bladder because the uterine fundus is soft and displaced laterally from midline. Vital signs are 37.6°C (99.8°F), pulse 90 beats/minute, respirations 20 breaths per minute, and BP 130/90 mm Hg. Which pharmacologic intervention is indicated?
Correct Answer: C
Rationale: The correct answer is C because prostaglandin analogs can be administered intramuscularly to stop uterine bleeding in this scenario. Oxytocin may be considered, but it is not administered in a piggyback solution. Methylergonovine is contraindicated in the presence of hypertension, which the patient has. Increasing parenteral fluids will not directly address the uterine bleeding issue.