ATI MATERNAL HEALTH FINAL REAL EXAM 100 QUESTIONS AND CORRECT DETAILED ANSWERS LATEST UPDATE ALREADY A GRADED The nurse is caring for a client who had been administered an anesthetic block during labor. For which risks should the nurse watch in the client? Select all that apply. - ANSWER>> incomplete emptying of bladder bladder distention urinary retention Many women have difficulty with feeling the sensation to void after giving birth if they have received an anesthetic block during labor, which inhibits neural functioning of the bladder. This client will be at risk for incomplete emptying, bladder distenti on, difficulty voiding, and urinary retention. Ambulation difficulty and perineal lacerations are due to episiotomy. The nurse is used to working on the postpartum floor taking care of women who have had normal vaginal births. Today, however, the nurse has been assigned to help care for women who are less than 24 hours post cesarean birth. The nurse realizes that some ar eas will not be assessed. What would the nurse leave out of the client assessments? - ANSWER>> perineum Usually a woman who experiences cesarean birth does not have an episiotomy, although rarely this may be the case. Healthy bonding behaviors are important to note when the nurse is assessing the new family. What would the nurse consider a warning sign that the mother and infant were not attaching as they should? - ANSWER>> Mother states she wanted a boy this time, not another girl. It is important to differentiate between a new parent who is nervous and anxious about her new role and one who is rejecting her parenting role. Warning signals of poor attachment include turning away from the newborn, refusing or neglecting to provide care, and disengagement from the newborn. Which maternal reaction is the most concerning? - ANSWER>> She neglects to engage with or provide care for the baby and shows little interest in it. A mother not bonding with the infant or showing disinterest is a cause for concern and requires a referral or notification of the primary health care provider. Some mothers hesitate to take their newborn and express disappointment in the way the baby looks , especially if they want a child of one sex and have a child of the opposite sex. Expressing doubt about the ability to care for the baby is not unusual, and being tearful for several days with difficulty eating and sleeping is common with "postpartum blues ". A mother just gave birth 3 hours ago. The nurse enters the room to continue hourly assessments and finds the client on the phone telling the listener about her fear while driving to the hospital and not making it in time. The mother finishes the call, and the nurse begins her assessment with which phrase? - ANSWER>>" It sounded like you had quite a time getting here. Would you like to continue your story?" The mother is going through the taking -in phase of relating events during her pregnancy and birth. The nurse can facilitate this phase by allowing the mother to express herself. Diverting the conversation, admonishing the mother, or warning of potential pr oblems does not accomplish this facilitation. When planning the care for a client during the first 24 hours postpartum, the nurse expects to monitor the client's pulse and blood pressure frequently based on the understanding that the client is at risk for which condition? - ANSWER>> hemorrhage The nurse should monitor the pulse and blood pressure frequently in the first 24 hours postpartum because the client is at greatest risk of hemorrhage. Hemorrhoids cause discomfort and contribute to constipation; this does not call for monitoring of pulse and blood pressure frequently. Increased coagulability causes increased risk of thromboembolism in the puerperium. Precipitous labor or instrument -assisted births pose an increased risk for cervical laceration. None of these conditions require monitoring o f pulse and blood pressure. A client in her sixth week postpartum reports general weakness. The client has stopped taking iron supplements that were prescribed to her during pregnancy. The nurse would assess the client for which condition? - ANSWER>> hypovolemia The nurse should assess the client for hypovolemia as the client must have had hemorrhage during birth and puerperium. Additionally, the client also has discontinued iron supplements. Hyperglycemia can be considered if the client has a history of diabetes. Hypertension and hyperthyroidism are not related to discontinuation of iron supplements. A woman has just given birth to a baby. Her prelabor vital signs were temperature: 98.8° F (37.1° C); blood pressure: 120/70 mm Hg; pulse; 80 beats/min. and respirations: 20 breaths/min. Which combination of findings during the early postpartum period are the most concerning? - ANSWER>> blood pressure 90/50 mm Hg, pulse 120 beats/min, respirations 24 breaths/min. The decrease in BP with an increase in HR and RR indicate a potential significant complication and are out of the range of normals from birth and need to be reported immediately. Shaking chills with a temperature of 100.3º F (37.9º C) can occur due to stress on the body and is considered a normal finding. A fever of 100.4º F (38º C) should be reported. The other options are considered to be within normal limits after giving birth to a baby. A woman who gave birth to a healthy baby 5 days ago is experiencing fatigue and weepiness, lasting for short periods each day. Which condition does the nurse believe is causing this experience? - ANSWER>> postpartum baby blues Postpartum baby blues is common in women after giving birth. It is a mild depression; however, functioning usually is not impaired. Postpartum blues usually peaks at day 4 or 5 after birth. Postpartum anxiety and postpartum depression do not usually start until at least 3 to 4 weeks and up to 1 year following the birth of a baby. Postpartum reaction is a term to include postpartum depression, anxiety, and psychosis. The nurse is caring for a client who had been administered an anesthetic block during labor. For which risks should the nurse watch in the client? Select all that apply - ANSWER>> incomplete emptying of bladder bladder distention urinary retention Many women have difficulty with feeling the sensation to void after giving birth if they have received an anesthetic block during labor, which inhibits neural functioning of the bladder. This client will be at risk for incomplete emptying, bladder distenti on, difficulty voiding, and urinary retention. Ambulation difficulty and perineal lacerations are due to episiotomy. Which lochia pattern should be reported immediately? - ANSWER>> moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5 Lochia by day 4 should be decreasing in amount, and the color should be changing to pink tinge. Red rubra on day 4 may indicate bleeding, and the healthcare provider should be notified. A moderate flow of lochia rubra on day 3 postpartum, changing to seros a on day 5, is a normal finding; as is lochia progressing from rubra to serosa to alba within 10 days of delivery; and so is moderate lochia rubra on day 3, mixed serosa and rubra on day 4, and light serosa on day 5. A client has just given birth to her second child and will breastfeed. Although she wants "lots of kids," she does not want to become pregnant again until her second child is at least 2 years old. The nurse would counsel her to start using birth control at what point? - ANSWER>>as soon as she resumes sexual activity She can ovulate even though she is not having a normal menstrual cycle. She needs to take precautions. Beginning to use birth control within 6 weeks, or within 18 months, or as soon as she stops breastfeeding is not affording her protection from getting pregnant. She should use mechanical means of birth control as soon as she resumes sexual activity.
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