Custom: Postpartum care Assessment ATI

A nurse is caring for a client who is 2 hr postpartum. The nurse notes that the client soaked a perineal pad in 10 min, the client's skin color is ashen, and she states she feels weak and light headed. After applying oxygen via nonrebreather face mask at 10 L/min which of the following actions should the nurse take next?

Massage the client's fundus to promote contractions.

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 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 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 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 is providing teaching about comfort measures for breast engorgement to a client who is postpartum and is breastfeeding. Which of the following statements by the client indicates a need for further teaching?

"I should apply hot packs to my breasts during feeding." Rationale:The application of heat promotes increased blood flow to the breasts, which are already engorged. This is not an appropriate intervention.

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 reinforcing teaching about reducing perineal infection with a client following a vaginal delivery. Which of the following should the nurse include in the teaching? (Select all that apply.)

- blot the perineal area dry after cleansing - clean perineal area from front to back - perform hand hygiene before and after voiding - wash the perineal area using a squeeze bottle of warm water after each void

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 caring for a client who reports unrelieved episiotomy pain 8 hr following a vaginal birth. Which of the following actions should the nurse take?

Apply an ice pack to the affected area.

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down" and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?

Ask the client if she has considered harming her newborn.

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 experienced a vaginal delivery 12 hr ago. When palpating the client's abdomen, at which of the following positions should the nurse expect to find the uterine fundus?

At the level of the umbilicus

A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications?

Disseminated Intravascular Coagulation Rationale: Clinical manifestations of disseminated intravascular coagulation (DIC) include oozing from intravenous access and venipuncture sites; petechiae, especially under the site of the blood pressure cuff; spontaneous bleeding from the gums and nose; other signs of bruising; and hematuria.

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?

Document the findings and continue to monitor the client.

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 experienced a vaginal birth 3 hr ago. Upon palpation, the fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus. Which of the following actions should the nurse complete at this time?

Have the client urinate.

A nurse is caring for a client who is postpartum who asks the nurse when her breast milk will "come in." Which of the following responses should the nurse make?

In 3 to 5 days

A nurse is performing a physical examination of a client who is 1 day postpartum. Which of the following findings requires immediate intervention?

Displaced fundus from the midline

A home health nurse is teaching a client who is breastfeeding about managing breast engorgement. Which of the following client statements indicates understanding of the teaching?

"I'll feed my baby every 2 hours."

A nurse is assessing a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three fingerbreadths below the umbilicus, lochia rubra is moderate, and the breasts are hard and warm to palpation. Which of the following interpretations of these findings should the nurse make?

Additional interventions are not indicated at this time Rationale: For this postpartum day, the client's fundal location and lochia characteristics are within the expected reference range. Breast fullness is typical, as this is the time when the breasts begin producing milk. Frequent breastfeeding and routine care can help relieve engorgement.

A nurse is caring for a client who is 12 hr postpartum following a vaginal delivery. Which of the following findings should the nurse expect?

Fundus firm, at the level of the umbilicus

A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

Fundus palpable to right of midline

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 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 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