Maternity Exam 3 - ATI questions &
correct answers 2024
Postpartum Physiological Adaptations - ANSWER-
A nurse is performing a fundal assessment for a client who is 2 days postpartum
and observes perineal pad for lochia. She notes pad to be saturated
approximately 12 cm with lochia that is bright red and contains small clots. Which
of the findings should the nurse document? - ANSWER- Moderate lochia rubra
During ambulation to the bathroom, a postpartum client experiences a gush of
dark red blood that soon stops. On assessment, a nurse finds the uterus to be
firm, midline, and at the level of the umbilicus. Which of the following findings
should the nurse interpret this data as being? - ANSWER- A normal postural
discharge of lochia
A nurse is completing postpartum discharge teaching to a client who had no
immunity to varicella and was given varicella vaccine. Which of the following
statements by the client indicates understanding of the teaching? - ANSWER- "I
need a second vaccination at my postpartum visit"
A nurse is assessing a postpartum client for fundal height, location, and
consistency. The fundus is noted to be displaced laterally to the right, and there
is uterine atony. The nurse should identify which of the following conditions as
the cause of the uterine atony? - ANSWER- Urinary retention
A nurse is caring for a client who is 1 hour postpartum following a vaginal birth
and experiencing uncontrollable shaking. The nurse should understand that the
shaking is due to which of the following factors? (select all) - ANSWER- - Change
in body fluids
- Metabolic effort of labor
, Baby-Friendly Care - ANSWER-
A nurse concludes that the father of an infant is not showing positive signs of
parent-infant bonding. He appears very anxious and nervous when the infant's
mother asks him to bring her the infant. Which of the following actions should the
nurse use to promote father-infant bonding? - ANSWER- Provide education about
the infant care when the father is present
A client is in the early postpartum period and is very excited and talkative. She is
repeatedly telling the nurse every detail of her labor and birth. Because the client
will not stop talking, the nurse is having difficulty completing the postpartum
assessments. Which of the following actions should the nurse take? - ANSWER-
Give the client time to express her feelings (taking-in phase)
A nurse is caring for a client who is 1 day postpartum. The nurse is assessing for
maternal adaptation and mother-infant bonding. Which of the following behaviors
by the client indicates a need for the nurse to intervene? (select all) - ANSWER- -
Demonstrates apathy when the infant cries
- Views infant's behavior as uncooperative during diaper change
A nurse is caring for a client who is 2 days postpartum. The client states, "my
four year old son was toilet trained and now he is frequently wetting himself."
Which of the following statements should the nurse provide to the client? -
ANSWER- "Your son is showing an adverse sibling response"
A nurse in the delivery room is planning to promote maternal-infant bonding for a
client who just delivered. Which of the following is the priority action by the
nurse? - ANSWER- Position the neonate skin-to-skin on the client's chest
Client Education and Discharge Teaching - ANSWER-
A nurse is conducting a home visit for a client who is 1 week postpartum and
breastfeeding. The client reports breast engorgement. Which of the following
recommendations should the nurse make? - ANSWER- "Apply cold compresses
between feedings"
A nurse is providing discharge instructions for a client. At 4 weeks postpartum,
the client should contact her provider for which of the following client findings? -
ANSWER- Sore nipple with cracks and fissures
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