ATI Capstone Class Exam Week 12 | Nurselytic

Questions 45

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ATI Capstone Class Exam Week 12 Questions

Extract:


Question 1 of 5

A nurse is caring for a client who is 1 hour postpartum and observes a large amount of lochia rubra and several small clots on the client’s perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

Correct Answer: D

Rationale: The correct answer is D: Document the findings and continue to monitor the client. At 1 hour postpartum, it is normal to have lochia rubra and small clots as the uterus is contracting to expel the placenta fragments. The firm, midline fundus at the umbilicus indicates proper involution. There is no indication of excessive bleeding or abnormal fundal position, so there is no immediate concern.
Therefore, the nurse should document the findings to establish a baseline and continue to monitor the client for any changes.


Choice A is incorrect because there is no indication to notify the provider at this time.
Choice B is unnecessary as the fundus is already firm.
Choice C is not the priority as the fundus position and consistency are appropriate. Monitoring and documentation are essential in this situation to detect any deviations from normal postpartum progress.

Question 2 of 5

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Question 3 of 5

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Question 4 of 5

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Question 5 of 5

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