ATI RN
Postpartum Hormonal Changes Questions
Question 1 of 5
Which measure is optimal in order to prevent abdominal distention following a cesarean birth?
Correct Answer: C
Rationale: The correct answer is C: Early and frequent ambulation. This measure is optimal to prevent abdominal distention following a cesarean birth because it helps promote bowel motility and gas expulsion. Ambulation stimulates peristalsis, preventing gas accumulation and reducing the risk of distention. Rectal suppositories (A) may help with constipation but do not address the root cause of distention. Carbonated beverages (B) can exacerbate bloating and gas production. Tightening and relaxing abdominal muscles (D) may provide some relief but are not as effective as promoting ambulation for preventing abdominal distention.
Question 2 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 3 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 4 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.
Question 5 of 5
The nurse includes the addition of ice sitz baths for the postpartum patient. Which assessment finding indicates the treatment has been effective?
Correct Answer: A
Rationale: The correct answer is A because the absence of swelling or edema to the perineal area indicates that the ice sitz baths have been effective in reducing inflammation and promoting healing. Swelling and edema are common postpartum, and the use of ice sitz baths can help reduce these symptoms. Choice B is incorrect because the patient complaining that the sitz bath is too cold does not provide information on the effectiveness of the treatment, only the patient's comfort level. Choice C is incorrect because the frequency of sitz baths does not necessarily indicate effectiveness. It is more important to assess the outcomes of the treatment rather than the number of baths taken. Choice D is incorrect because the approximation of perineal laceration edges may be influenced by other factors such as suturing technique, rather than the effectiveness of the ice sitz baths.