ATI RN
Postpartum Hormonal Changes Questions
Question 1 of 5
Which of the following is a priority nursing diagnosis for a woman, G10 P6226, who is PP1 from a spontaneous vaginal delivery with a significant postpartum hemorrhage?
Correct Answer: C
Rationale: The priority nursing diagnosis for a woman who is PP1 from a spontaneous vaginal delivery with significant postpartum hemorrhage is C) Fluid volume deficit related to blood loss. This is the correct answer because postpartum hemorrhage can lead to a rapid loss of blood volume, potentially resulting in hypovolemic shock and other serious complications. Replenishing the lost fluids is crucial to stabilize the woman's condition and prevent further complications. Option A) Alteration in comfort related to afterbirth pains is important but not the priority in this situation. Pain management is essential, but addressing fluid volume deficit takes precedence due to the potential life-threatening consequences of hemorrhage. Option B) Risk for altered parenting related to grand multiparity is not a priority in the immediate postpartum period. While it is important to support new mothers in their parenting journey, addressing a physiological issue like fluid volume deficit is more urgent. Option D) Risk for sleep deprivation related to mothering role is also not the priority in this scenario. While fatigue and sleep deprivation can impact the new mother's well-being, addressing the physical health issue of fluid volume deficit is more critical for her immediate recovery and safety. In an educational context, understanding the hierarchy of nursing priorities is crucial for providing effective and efficient care. By prioritizing the most critical needs of the patient, nurses can ensure that life-threatening issues are addressed promptly, leading to better patient outcomes. In the case of postpartum hemorrhage, identifying and managing fluid volume deficit is a priority to stabilize the woman's condition and prevent complications.
Question 2 of 5
A nurse is assessing a 1-day postpartum client who had a spontaneous vaginal delivery over an intact perineum. The fundus is firm at the umbilicus, lochia moderate, and perineum edematous. One hour after receiving ibuprofen 600 mg po, the client is complaining of perineal pain at level 9 on a 10-point scale. Based on this information, which of the following is an appropriate conclusion for the nurse to make about the client?
Correct Answer: C
Rationale: In this scenario, option C, "She may have a hidden laceration," is the most appropriate conclusion for the nurse to make about the client. This is because despite the client having a spontaneous vaginal delivery over an intact perineum, the persistence of severe perineal pain (level 9 on a 10-point scale) one hour after taking ibuprofen could indicate a hidden laceration that was not initially detected during the assessment. Option A, "She should be assessed by her doctor," could be considered less urgent compared to the potential of a hidden laceration causing the severe pain. Option B, "She should have a sitz bath," might provide some relief but does not address the underlying cause of the severe pain. Option D, "She needs a narcotic analgesic," is not the first-line treatment for postpartum perineal pain and should be avoided unless absolutely necessary due to potential side effects and risks. From an educational perspective, it is crucial for nurses to understand the significance of persistent severe pain postpartum, especially in the context of perineal discomfort. This case highlights the importance of thorough assessment, including the possibility of hidden lacerations, to ensure appropriate and timely interventions for postpartum clients. Early detection and management of complications can significantly impact the client's recovery and overall postpartum experience.
Question 3 of 5
A woman who wishes to breastfeed advises the nurse that she has had breast augmentation surgery. Which of the following responses by the nurse is appropriate?
Correct Answer: D
Rationale: The appropriate response by the nurse is option D) Women who have implants are often able exclusively to breastfeed. This response is correct because breast implants do not typically interfere with a woman's ability to breastfeed. Breast augmentation surgery usually does not affect the function of the mammary glands responsible for milk production. Option A is incorrect because breast implants do not inherently contaminate breast milk with toxins. Option B is incorrect as it inaccurately suggests that women who need breast implants lack sufficient glandular tissue for breastfeeding. Option C is also incorrect as babies can usually latch onto the nipples of women with breast implants without significant difficulty. Educationally, it is crucial for healthcare providers to have accurate information about the impact of breast augmentation on breastfeeding to provide appropriate support and guidance to women. Understanding that breast implants generally do not impede breastfeeding can help alleviate concerns and encourage women who have had breast augmentation surgery to confidently pursue breastfeeding if they choose to do so.
Question 4 of 5
The nurse is discussing the neonatal blood screening test with a new mother. The nurse knows that the teaching was successful when the mother states that the test screens for the presence in the newborn of which of the following diseases? Select one that doesn't apply
Correct Answer: D
Rationale: In this scenario, option D, "Cerebral palsy," is the correct answer for the neonatal blood screening test. This test is designed to screen for metabolic and genetic disorders present in newborns that may not be apparent at birth. Cerebral palsy is a neurodevelopmental disorder that affects movement and muscle coordination, and it is not detected through a blood screening test. Options A, B, and C are incorrect because they are conditions that can be detected through neonatal blood screening tests. Hypothyroidism, sickle cell disease, and galactosemia are all metabolic disorders that can be identified early through such screening tests, allowing for prompt intervention and management to prevent complications and promote the baby's well-being. Educationally, understanding the purpose of neonatal blood screening tests is crucial for new parents to grasp the importance of early detection and intervention in managing potential health conditions in their newborns. By explaining the rationale behind each answer choice, nurses can enhance parental knowledge and empower them to be proactive in their child's healthcare from the very beginning.
Question 5 of 5
A full-term newborn was just born. Which nursing intervention is important for the nurse to perform first?
Correct Answer: B
Rationale: In the immediate postpartum period, assessing the Apgar score is crucial as it provides a quick snapshot of the newborn's overall condition and helps determine if any immediate interventions are needed. The Apgar score evaluates the baby's heart rate, respiratory effort, muscle tone, reflex irritability, and color at one minute and five minutes after birth. This quick assessment guides the nurse in determining the need for resuscitative measures or additional monitoring. Removing wet blankets (option A) is important for maintaining the newborn's body temperature but is not as time-sensitive as assessing the Apgar score. Inserting eye prophylaxis (option C) and eliciting the Moro reflex (option D) are important assessments but are not the priority immediately after birth. In an educational context, understanding the significance of the Apgar score and its role in the initial assessment of newborns is essential for nurses and other healthcare providers working in labor and delivery or postpartum units. This knowledge ensures that appropriate care is provided promptly, promoting the well-being of the newborn and facilitating early interventions if necessary.