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ATI Detailed Answer Key Postpartum & Newborn_Practice Questions
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ATI Detailed Answer Key Postpartum & Newborn_Practice Questions
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Detailed Answer KeyPostpartum & Newborn_Practice Questions
Created Page1.A nurse is caring for a client who is postpartum and received methylergonovine. Which of the following findings indicates that the medication was effective?
A.Fundus firm to palpation
Rationale: Methylergonovine is an oxytocic medication that is administered to promote uterine
contractions. This medication is indicated for treatment of postpartum hemorrhage
caused by uterine atony or subinvolution; the desired effect is an increase in uterine
tone.
B.Increase in blood pressure
Rationale: A rise in blood pressure is an adverse effect of the medication.
C.Increase in lochia
Rationale: This finding would indicate the medication was not effective.
D.Report of absent breast pain
Rationale: Methylergonovine has no effect on breast discomfort.
2.A nurse is assessing a client who is 4 hr postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority?
A.Saturated perineal pad in 30 min
Rationale: The client will have lochia rubra for the first 1 to 3 days. A saturated perineal pad in
15 min or less can indicate excessive bleeding. Therefore, the nurse should not identify this as the priority finding. The nurse should also monitor for blood under the client's buttocks.
B.Deep tendon reflexes 4+
Rationale: Deep tendon reflexes 4+ are hyperactive and indicate that the client is at greatest risk for preeclampsia and seizures. The nurse should identify this as the priority finding. The nurse should also monitor for headaches, visual disturbances and epigastric pain. The provider will likely prescribe magnesium sulfate IV infusion.
C.Fundus at level of umbilicus
Rationale: The client's fundus should be firm, midline, and at the level of the umbilicus for the first 24 hr after delivery. The fundus will involute approximately 1 cm/day and will descend 1 to 2 cm/day. Therefore, the nurse should not identify this as the priority finding.
D.Approximated edges of episiotomy
Rationale: Approximated edges of the episiotomy indicate good wound healing.
Therefore, the nurse should not identify this as the priority finding. Redness,
warmth, and drainage can indicate infection. Detailed Answer Key
Postpartum & Newborn_Practice Questions
Created Page3.A nurse is caring for a client who is 1 hr 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?
A.Document the findings and continue to monitor the client.
Rationale: These are expected findings. At 1 hr postpartum, lochia rubra should be intermittent and associated with uterine contractions. The volume of lochia resembles that of a heavy menstrual period. Small clots are common. The nurse should document the findings and continue to monitor the client.
B.Notify the client’s provider.
Rationale: These are expected findings, so there is no need to notify the provider.
C.Increase the frequency of fundal massage.
Rationale: These are expected findings and the fundus is already firm. Increasing the frequency of fundal massage is not indicated at this time.
D.Encourage the client to empty her bladder.
Rationale: These are expected findings, and the fundus is firm at the midline. If the fundus was
deviated, this would be an indication of a distended bladder and the client should be
encouraged to void to prevent uterine atony.
4.A nurse is teaching a client who is postpartum and has been diagnosed with iron deficiency anemia. Which of the following dietary recommendations should the nurse include in the teaching plan?
A.Yogurt and mozzarella
Rationale: Yogurt and mozzarella cheese are sources of calcium and protein and are not high in iron and therefore would not be recommended for this client as sources of iron.
B.Spinach and beef
Rationale: Spinach and beef are high in iron and would be recommended for this client.
C.Milk and turkey slices
Rationale: Milk is a source of calcium and protein, and turkey is a source of protein. They are not high in iron and would not be recommended for this client as sources of iron.
D.Fish and cottage cheese
Rationale: Fish is a source of protein, and cottage cheese is a source of protein and calcium. They are not high in iron and would not be recommended for this client as sources of iron.
5.A nurse is performing a physical examination of a client who is 1 day postpartum. Which of the following findings requires immediate intervention? Detailed Answer Key
Postpartum & Newborn_Practice Questions
Created PageA.Decreased urge to void
Rationale: This is an expected finding in the postpartum period and does not require immediate intervention. Birth trauma, increased bladder capacity after childbirth, and anesthesia can cause a decreased urge to void. Pelvic soreness caused by the forces of labor, vaginal lacerations, or an episiotomy reduces or alters the voiding reflex. The nurse should monitor the client’s voiding pattern.
B.Increased urine output
Rationale: Within 12 hr of birth, clients begin to lose the excess tissue fluid accumulated during pregnancy.
Postpartum diuresis is caused by decreased estrogen levels. This is an expected finding and does not require immediate intervention.
C.Displaced fundus from the midline
Rationale: A distended bladder can cause uterine atony and lateral displacement of the fundus
from the midline of the lower abdomen, usually to the right. This requires immediate intervention because the distended bladder pushes the uterus up and to the side, which prevents it from contracting firmly. Uterine atony results from the inability of the uterine muscle to contract adequately after birth. This can lead to postpartum hemorrhage.
D.Fundal height below the umbilicus
Rationale: Involution is the return of the uterus to a nonpregnant state. At the end of the third stage of labor, the uterus is in the midline, approximately 2 cm below the level of the umbilicus. Within 12 hr, the fundus rises to approximately the level of the umbilicus. The fundus descends 1 to 2 cm every 24 hr. Therefore, at 1 day postpartum, the fundal height should be 1 to 2 cm (fingerbreadths) below the umbilicus. This is an expected finding and does not require immediate intervention.
6.A nurse is caring a client who is 3 days postpartum and is attempting to breastfeed. Which of the following findings indicate mastitis?
A.Swelling in both breasts
Rationale: Because the swelling is present in both breasts and there is no redness or pain, this
client is likely to have engorgement. The nurse should assist the client to breastfeed frequently and apply ice packs or cold compresses after breastfeeding.
B.Cracked and bleeding nipples
Rationale: Tenderness of the nipples is expected in the first few days of breastfeeding. Cracking and bleeding nipples, however, is an indication that the infant's position and/or feeding method is incorrect. The nurse should instruct the mother to clean the nipples with water and apply a thin layer of a topical antibiotic cream or ointment after breastfeeding.
C.Red and painful area in one breast
Rationale: Mastitis often appears as a red, hard, and painful area on the breast, commonly in the upper outer quadrant. Although mastitis can occur in both breasts, it is usually unilateral. A client who has mastitis can also influenza-like manifestations, such as fever, chills, headache, and myalgia. After delivery, the nurse should instruct the client to observe the breasts for indications of mastitis and to notify her provider if they occur. Detailed Answer Key
Postpartum & Newborn_Practice Questions
Created PageD.A white patch on a nipple
Rationale: A small white area, or pearl, on the nipple is an indication of a blocked milk duct. Plugged milk ducts occur most frequently as a result of inadequate emptying of milk from the breast. The nurse should apply warm compresses to the breast and nipple prior to feeding to help promote the emptying of the breast and clearing of the blocked milk duct.
7.A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse’s priority?
A.The client reports weakness of the lower extremities.
Rationale: Weakness of the lower extremities can limit the client's ability to move and maintain control during labor; however, another finding is the nurse's priority.
B.Blood pressure 80/56 mm Hg
Rationale: When using the airway, breathing, circulation approach to client care, the nurse's priority finding is a blood pressure of 80/56, which indicates hypotension. The client's blood pressure is not adequate to sustain uteroplacental perfusion and oxygen to the fetus, which can lead to respiratory distress and possibly death.
C.Temperature 38.2°C (100.8°F)
Rationale: A temperature of 38.2°C (100.8°F) can indicate infection; however, another finding is the nurse's priority.
D.The client reports perfuse itching.
Rationale: Perfuse itching may indicate an adverse reaction to the opioid analgesia; however, another finding is the priority.
8.A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?
A.Evaluate the firmness of the uterus.
Rationale: The first action the nurse should take using the nursing process is to assess the client. A blood pressure of 60/50 mm Hg can indicate postpartum hemorrhage; therefore, the first action the nurse should take is to evaluate the firmness of the uterus to determine if there is uterine atony.
B.Initiate oxygen therapy by nonrebreather mask.
Rationale: The nurse should initiate oxygen therapy via a nonrebreather mask to improve oxygen delivery to the client; however, there is another action the nurse should take first.
C.Administer oxytocin infusion.
Rationale: The nurse should administer oxytocin infusion to increase contractility of the uterus; however, there is another action the nurse should take first.
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