ATI Postpartum Physiological Assessments and Nursing Care
12. The nurse is performing a uterus assessment on a patient who is 20 hours postpartum. The nurse finds the fundus of the uterus to be soft and boggy. In addition, the uterus is displaced to the left and moderate bleeding is noted. If the uterus does not respond to uterine massage, which actions does the nurse implement? Select all that apply. 1. Assist the patient to the bathroom to void. 2. Reassess to determine response to treatment. 3. Administer oxytocin as prescribed. 4. Place an emergency call to the HCP. 5. Make the patient NPO for surgery.
ANS: 1, 2, 3, 5 1 This is correct. Because of the displacement of the uterus to the left, the nurse concludes that a full bladder may be the cause. The nurse needs to assist the patient to the bathroom to void. 2 This is correct. After the nurse implements all nursing and prescribed interventions, the nurse will reassess the uterus to evaluate and determine the response to treatment. 3 This is correct. When the uterus is boggy and bleeding is moderate, the nurse will administer oxytocin as prescribed in the HCP's postpartum orders. 4 This is incorrect. The nurse will contact the HCP after interventions are implemented and reassessment has taken place. There is no need to place an emergency call to the HCP prior to this. An emergency call is appropriate if improvement is not noted. 5 This is correct. If the patient does not respond to nursing and prescribed interventions, the nurse may make the patient NPO for anticipated surgery. The lack of response may indicate complications such as retained placental tissue or birth trauma. Continued uterine atony can lead to postpartum hemorrhage and requires assessment and potentially further treatment by the woman's health care provider.
13. The nurse is preparing to perform a visual assessment of the perineum of a postpartum patient. The nurse will use the REEDA acronym. Which specific assessments are covered by REEDA? Select all that apply. 1. Perineal coloration 2. Suture line appearance 3. Amount of swelling 4. Description of pain 5. Soft tissue trauma
ANS: 1, 2, 3, 5 1 This is correct. The acronym REEDA stands for redness, edema, ecchymosis, discharge, approximation of edges of episiotomy or laceration. Redness is indicative of perineal coloration. 2 This is correct. The acronym REEDA stands for redness, edema, ecchymosis, discharge, approximation of edges of episiotomy or laceration. Suture line appearance is indicative of approximation of edges of episiotomy or laceration. 3 This is correct. The acronym REEDA stands for redness, edema, ecchymosis, discharge, approximation of edges of episiotomy or laceration. The amount of swelling is indicative of edema. 4 This is incorrect. The acronym REEDA stands for redness, edema, ecchymosis, discharge, approximation of edges of episiotomy or laceration. The patient's description of pain is not specifically addressed by a REEDA assessment. 5 This is correct. The acronym REEDA stands for redness, edema, ecchymosis, discharge, approximation of edges of episiotomy or laceration. Soft tissue trauma is frequently accompanied by bruising and is indicative of ecchymosis
16. The nurse is reviewing the medical record for a patient who is postpartum. The nurse notices the patient is rubella-nonimmune. Which information does the nurse present to the patient? Select all that apply. 1. The risks to the fetuses of any future pregnancies. 2. The patient will need to be immunized before discharge. 3. Breastfeeding should be avoided for 24 hours after immunization. 4. Maternal immunization carries over to the neonate. 5. Pregnancy should be avoided for 4 weeks.
ANS: 1, 2, 5 1 This is correct. Fetuses exposed to rubella during the first trimester are at risk for birth defects that include deafness, blindness, heart defects, and mental retardation. 2 This is correct. The patient should be immunized before discharge so that immunity is established before the possibility of another pregnancy. Women cannot be immunized during pregnancy. 3 This is incorrect. There is no reason to refrain from breastfeeding for any period of time after a rubella vaccine is received. 4 This is incorrect. Maternal immunity to rubella does not carry over to the neonate. The infant will be immunized for rubella and other diseases at designated times. 5 This is correct. Although the risk of a fetus developing birth defects from the vaccine is extremely low, the patient is advised to avoid pregnancy for 4 weeks
15. The nurse is assessing patients who are postpartum. Which patients does the nurse identify as being at increased risk for respiratory complications? Select all that apply. 1. The patient who was placed on bedrest for threatened abortion 2. The patient with preeclampsia treated with magnesium sulfate 3. The patient with a preexisting diagnosis of diabetes mellitus 4. The patient who delivered a neonate after regional anesthesia 5. The patient who received large amounts of IV fluid due to blood loss
ANS: 1, 2, 5 1 This is correct. The nurse recognizes that the patient placed on bedrest for a threatened abortion is a risk for developing a pulmonary embolus. 2 This is correct. Treating a patent with preeclampsia with magnesium sulfate places the patient at an increased risk for respiratory system complications. 5 This is correct. The patient who receives a large amount of IV fluids because of blood loss is at risk for respiratory system complications related to the potential for fluid overload.
6. The nurse is preparing a postpartum patient for discharge. Which patient teaching is most important for the nurse to provide? 1. The signs and symptoms of uterine infection 2. The signs and symptoms of secondary hemorrhage 3. The signs and symptoms of postpartum depression 4. The signs and symptoms of a boggy uterus
ANS: 2 This is correct. It is most important for the nurse to provide teaching regarding the signs and symptoms of secondary hemorrhage, which often occurs after the patient is discharged. The patient needs to understand the normal progression of lochia and uterine involution, and report abnormal amounts of bleeding. 3
4. A postpartum patient calls the OB office 8 days following a vaginal delivery. The patient reports concern regarding vaginal bleeding. Which patient-reported symptom causes the nurse concern? 1. Increased flow noticed with physical activity 2. A description of the lochia as being red in color 3. Discharge that is noted to have a fleshy odor 4. Bleeding that is described as scant
ANS: 2 This is correct. The lochia during the period of 4 to 10 days is described as lochia serosa (pink or brown color). The nurse will be concerned if the patient reports lochia that is red in color, which is indicative of bleeding.
5. The nurse is collecting the urine of a postpartum patient who is passing large clots. For which reason does the nurse examine the large collected clots? 1. To validate the presence of clotting 2. To determine the presence of tissue 3. To obtain an accurate description 4. To document the number of clots
ANS: 2 This is correct. The nurse collects the large clots in order to examine them for the presence of tissue, which indicates retained placenta tissue. Retained placental tissue can interfere with uterine involution and lead to excessive bleeding.
7. The nurse in a postpartum unit frequently teaches patients regarding breast care. Which teaching is most helpful to the breastfeeding patient? 1. Run warm water over breasts while in the shower. 2. Wear a supportive bra for 24 hours a day. 3. Express milk by a breast pump or manually. 4. Take analgesics for breast pain management.
ANS: 3 This is correct. Expressing milk with a breast pump or manually is specifically helpful to the breastfeeding patient. The process can help relieve breast engorgement, maintain a milk supply for the neonate/infant who cannot suckle at the breast, and/or provide breast milk for the neonate/infant who is separated from the mother.
17. In an attempt to improve the effectiveness of postpartum teaching, the nurse uses the AWHONN acronym POST BIRTH. Which teaching points require the patient to call for 911 assistance? Select all that apply. 1. Bleeding that soaks a pad per hour 2. A bad headache with vision changes 3. Thoughts of hurting self or baby 4. Signs an incision is not healing 5. A red, swollen leg painful to touch
ANS: 3 This is correct. The AWHONN acronym states the mother should call 911 immediately if she has thoughts of self-harm or harm to her baby. This can be indicative of severe postpartum depression or psychosis.
10. A patient who is 12 hours postpartum after a vaginal delivery continues to have difficulty in initiating urination. The nurse is aware that an integrative method used when a woman is unable to void is peppermint oil. In which manner will the peppermint oil be used? 1. A thin layer is applied to the urinary meatus. 2. A small amount on a cotton ball is left at the bedside. 3. A small amount is added to the water of a vaporizer. 4. A saturated cotton ball is placed in a "hat" on the toilet
ANS: 4 This is correct. The nurse will place a cotton ball saturated with peppermint oil in a "hat" used to collect urine when the patient voids in the toilet. A small amount of water is added to the "hat," and the resulting vapors have a relaxing effect on the urinary sphincter.
2. The nurse is palpating a patient's uterus 12 hours after a vaginal delivery. For which reason does the nurse place one hand just above the symphysis pubis? 1. To prevent uterine prolapse. 2. To prevent uterine movement 3. To prevent uterine hemorrhage 4. To prevent uterine inversion
ANS: 4 This is correct. When palpating the patient's uterus 12 hours postpartum, the nurse supports the lower uterine segment by placing one hand just above the symphysis pubis. Pregnancy stretches the ligaments that hold the uterus in place, and fundal pressure could result in uterine inversion
19. After pregnancy and birth, a mother may notice a condition called diastasis recti abdominis, which is a(n) ____________________ of the rectus muscle
ANS: separation After birth, the abdominal muscles experience reduced tone and the abdomen appears soft and flabby. Some women experience a separation of the rectus muscle, which is noted as diastasis recti abdominis. This separation becomes less apparent as the body returns to a prepregnant state.
1. A multiparous patient reports severe uterine cramps the first day after a vaginal delivery. The nurse is aware the patient is breastfeeding and associates the patient's pain primarily with which occurrence? 1. An increase in oxytocin release related to the newborn suckling 2. The presence of intense afterbirth pains related to multiparity 3. An expected response to the daily administration of oxytocin 4. The efforts of the uterus to return to a prepregnancy condition
ANS: 1 This is correct. The suckling of a newborn during breastfeeding will stimulate an increased release of oxytocin, which in turn stimulates the uterus to remain contracted
18. The nurse is providing teaching to a patient who is breastfeeding a newborn. The patient expresses interest in maintaining a healthy nutritional status for both her and her baby. Which information does the nurse present to meet the patient's need? Select all that apply. 1. Increase caloric intake by 500 to 1,000 per day. 2. Drink 2 to 3 liters of fluid each day. 3. Abstain from the intake of alcohol. 4. Eat fresh fruits and vegetables. 5. Avoid the intake of processed foods.
ANS: 1, 2 1 This is correct. The lactating mother should increase her calorie intake by 500 to 1,000 calories daily. 2 This is correct. The lactating mother will need to drink approximately 2 to 3 liters of fluid daily.
14. A postpartum patient states, "I am really in pain." For which sources of pain will the nurse specifically assess the patient? Select all that apply. 1. Uterine contractions 2. Perineal trauma 3. Breast engorgement 4. Hemorrhoids 5. General soreness
ANS: 1, 2, 3, 4, 5 1 This is correct. The nurse will specifically assess for uterine contractions or afterpains being a source of pain. 2 This is correct. The nurse will specifically assess for perineal trauma being a source of pain. Perineal trauma includes episiotomy, lacerations, and/or ecchymosis. 3 This is correct. The nurse will specifically assess for breast engorgement as being a source of pain. Breastfeeding mothers may also have nipple pain caused by improper nipple latching by the neonate. 4 This is correct. The nurse will specifically assess for hemorrhoids as being a source of pain. 5 This is correct. The nurse will specifically assess for general soreness as being a source of pain.
8. The nurse is providing care to a patient who is postpartum. Using anatomy and physiology knowledge, which expectation does the nurse relate to the cardiovascular system? 1. Patient reporting of being cold related to blood loss 2. WBC laboratory level of 30,000/mm a few hours after delivery 3. Risk for hemorrhage due to decrease in circulating clotting factors 4. A normal postpartum hemoglobin laboratory value of less than 11 g/dL
ANS: 2 This is correct. The nurse is aware that a WBC lab level of 30,000/mm a few hours after delivery is normal and as the result of the stress of labor and birth.
9. Prior to discharge from the birthing center, the nurse informs the patient that she will receive vaccines for rubella, hepatitis B, pertussis, and influenza. For which reason does the nurse explain the need for the vaccinations? 1. Discharge with a neonate is discouraged if the mother is not vaccinated. 2. Vaccinating the mother will protect the neonate from serious illnesses. 3. The mother's immune system has been suppressed during pregnancy. 4. Vaccination is more easily accomplished while the mother is under medical care
ANS: 2 This is correct. When the mother is vaccinated for rubella, hepatitis B, pertussis, and influenza, the neonate is also less likely to be infected with or affected by these diseases. Hepatitis B, pertussis, and influenza can be life-threatening for a neonate. The mother should be immunized for rubella to avoid contracting the disease during a future pregnancy.
11. The nurse is discussing contraception with a couple before discharge following the birth of a first child. The couple are uncertain about the method but are certain about avoiding pregnancy for at least 2 years. Which method does the nurse recommend? 1. Emergency contraceptives 2. Oral estrogen/progesterone pill 3. Depo-Provera 4. Natural family planning
ANS: 3 This is correct. Depo-Provera is a likely suggestion by the nurse. This method has a 3% failure rate, is injectable every 3 months, and has few non-life-threatening side effects. It may result in delayed fertility
3. The nurse is providing postpartum care to a patient 24 hours after a vaginal delivery. Which action does the nurse perform prior to assessing the patient's uterus? 1. Place the patient on the left side. 2. Assess the passage of lochia. 3. Ask the patient to void. 4. Administer a dose of oxytocin
ANS: 3 This is correct. The nurse needs to have the patient void prior to palpating the uterus in order to accurately assess uterine placement and tone. An overdistended bladder can result in uterine displacement and atony
