ATI LPN
ATI PN Maternal Newborn 2023 II Questions
Extract:
Vital Signs 0700: Temperature: 36.2°C (97.2°F), Heart rate: 80/min, Respiratory rate: 16/min, Blood pressure: 136/82 mm Hg. 1100: Temperature: 37.2°C (99.0°F), Heart rate: 85/min, Respiratory rate: 18/min, Blood pressure: 136/86 mm Hg, Pulse oximetry: 99%. Nurses' Notes 0700: The client's breasts were soft, and nipples were intact. The uterus was palpated as firm, midline, and at the level of the umbilicus. There was a moderate amount of lochia rubra. The episiotomy site was well approximated with mild edema and ecchymosis. The client reported pain as 2 on a scale of 0 to 10. She was able to void spontaneously, with no bladder distention. Deep tendon reflexes were 1+. Peripheral edema was 2+ in bilateral lower extremities. 1100: The client's breasts remained soft, and nipples were intact. The uterus was palpated as soft with lateral deviation and 1 cm above the umbilicus. There was a large amount of lochia rubra. The episiotomy site was well approximated with mild edema and ecchymosis. The client reported pain as 3 on a scale of 0 to 10. Deep tendon reflexes were 1+. Peripheral edema was 2+ in bilateral lower extremities.
Question 1 of 5
Select the 3 findings that require immediate follow-up.
Correct Answer: B,F,G
Rationale: Lateral deviation of the uterus can indicate bladder distension, which can interfere with uterine contraction and increase the risk of postpartum hemorrhage. A soft uterine tone indicates uterine atony, which can lead to postpartum hemorrhage. A large amount of lochia rubra can be a sign of postpartum hemorrhage.
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Question 2 of 5
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Question 5 of 5
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