Custom: Postpartum care Assessment
ATI
A nurse is caring for a client 2 hr after a spontaneous vaginal birth and
the client has saturated two perineal pads with blood in a 30-min period.
✅✅
Which of the following is the priority nursing intervention at this time? -
-Palpate the client's uterine fundus.
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? - -Evaluate the firmness of the
uterus.
A nurse is caring for a client who is 5 hr postpartum following a vaginal
birth of a newborn weighing 9 lb 6 oz. (4252 g). The nurse should
✅✅
recognize that this client is at risk for which of the following postpartum
complications? - -Uterine atony
A nurse is caring for a client who is 4 hr postpartum following a vaginal
✅✅
birth. The client has saturated a perineal pad within 10 min. Which of the
following actions should the nurse take first? - -Massage the
client's fundus.
A nurse is caring for a client who is 2 days postpartum. Complete the
diagram by dragging 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. - -- Apply ice packs to the perineum.
- Initiate intravenous infusion of oxytocin.
- Perineal hematoma
- Rectal pain
- Hemoglobin and hematocrit
✅✅
A nurse is caring a client who is 3 days postpartum and is attempting to
breastfeed. Which of the following findings indicate mastitis? - -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.
A nurse is caring for a client who is 1 day postpartum and is taking a sitz
✅✅
bath. To determine the client's tolerance of the procedure, which of the
following assessments should the nurse perform? - -Pulse rate
A nurse is caring for a client who is postpartum and finds the fundus
✅✅
slightly boggy and displaced to the right. Based on these findings, which
of the following actions should the nurse take? - -Assist the client
to the bathroom to void.
A nurse is caring for a client who is 36 hr postpartum. After reviewing the
✅✅
information in the client's medical record, which of the following
complications pose a greater risk for the client? - -The complication
that poses the greatest risk for the client is
(hemorrhage)
as evidenced by their
(amount of lochia).
A nurse receives report about assigned clients at the start of the shift.
✅✅
Which of the following clients should the nurse plan to see first? -
-A client who experienced a cesarean birth 4 hr ago and reports
pain
A nurse is assessing a client who is 8 hr postpartum and multiparous.
✅✅
Which of the following findings should alert the nurse to the client's need
to urinate? - -Fundus three fingerbreadths above the umbilicus
A nurse is reinforcing teaching about reducing perineal infection with a
client following a vaginal delivery. Which of the following should the
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