ATI LPN
ATI PN Maternal Newborn 2023 II Questions
Extract:
A nurse is collecting data from a client who is 18 hr postpartum.
Question 1 of 5
Which of the following findings require the nurse to intervene?
Correct Answer: A
Rationale: Fundus located to the right of the umbilicus requires intervention. This can indicate a full bladder, which can inhibit uterine contraction and increase the risk of postpartum hemorrhage.
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 2 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.
Extract:
A nurse is reinforcing teaching with a client who tested positive for group B streptococcus β-hemolytic (GBS) during a prior pregnancy and is at 30 weeks of gestation.
Question 3 of 5
Which of the following statements should the nurse make?
Correct Answer: A
Rationale: You will be tested again for GBS at about 36 weeks of gestation.â€. This is correct because retesting for GBS at 35-37 weeks of gestation is standard practice to identify colonization status before delivery, which helps in planning intrapartum antibiotic prophylaxis.
Extract:
A nurse is reinforcing teaching about perineal care to a client who is 2 hours postpartum and has an episiotomy and hemorrhoids.
Question 4 of 5
Which of the following statements by the client indicates understanding of the teaching?
Correct Answer: D
Rationale: Applying witch hazel pads after urination helps reduce swelling, provides soothing relief, and promotes healing for both hemorrhoids and episiotomy sites. Witch hazel has natural astringent properties that are beneficial for postpartum perineal care.
Extract:
Vital Signs: Temperature: 38.4°C (101.1°F), Heart rate: 108/min, Respiratory rate: 20/min, Blood pressure: 118/72 mm Hg. History and Physical: The client is gravida 1 para 1, at 41 weeks of gestation. The client gave birth via cesarean following prolonged rupture of membranes and cephalopelvic disproportion. Assessment: The client's breasts are starting to feel firmer and heavier, and she denies nipple discomfort. The client is bottle-feeding. The uterus is boggy and tender to palpation, with the fundus at the umbilicus. The lochia discharge is moderate, dark brown, and foul-smelling. The client reports frequent voiding without difficulty. Bilateral edema is noted in the lower extremities, without pain, warmth, or tenderness.
Question 5 of 5
Complete the diagram by selecting from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Correct Answer: A
Rationale: Endometritis is indicated by fever, tender boggy uterus, and foul-smelling lochia. Actions: Administer antibiotics; monitor oxytocic medication. Parameters: Monitor temperature and lochia.