ATI post partum 2019

unrelieved episiotomy pain 8 hr following vaginal birth

apply ice pack to affected area

postpartum and finds fundus slightly boggy + displaced to the R

assist client to bathroom to void

A nurse is caring for a client who experienced a vaginal delivery 12 hr ago. When palpating the clients abdomen, at which of the following positions should the nurse expect to find the uterine fundus? A. at level of umbilicus B. 2 cm above umbilicus C. one fingerbreath above symphysis pubis D. to R of umbilicus

A. at level of umbilicus

A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the client BP is 60/50. Which of the following actions should the nurse take first? A. eval firmness of uterus B. initiate O2 therapy via nonrebreather C. admin oxytocin infusion D. obtain type and crossmatch

A. eval firmness of uterus -determine uterine atony

A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated 2 perineal pads with blood in a 30 min period. Which of the following is the priority nursing intervention at this time? A. palpate client uterine fundus B. assist the client on a bedpan to urinate C. prepare to admin oxytocic meds D. increase fluid intake

A. palpate client uterine fundus -assess BEFORE interventions

A nurse is teaching a client who is postpartum and has a new rx for an injection of Rh immunoglobulin. Which of the following should be included in the teaching? A. prevents the formation of Rh antibodies in mothers who are Rh neg B. destroys Rh antibodies in mothers who are Rh neg C. destroys Rh antibodies in newborns who are Rh pos D. prevents formation of Rh antibodies in newborns who are Rh pos

A. prevents the formation of Rh antibodies in mothers who are Rh neg

A nurse in a clinic 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? A. assist the fam to ID prior use of positive coping skills in a fam crises B. ask pt if she has considered harming her newborn C. anticipate a rx by provider for antidepressant D. reinforce postpartum and newborn care discharge teaching

B. ask pt if she has considered harming her newborn

A nurse is assessing a client who is 4 hr postpartum following a vaginal delivery. Which of the following findings should the nurse ID as the priority? A. saturated perineal pad in 30 min B. deep tendon reflex 4+ C. fundus at level of umbilicus D. approximated edges of episiotomy

B. deep tendon reflex 4+ -hyperactive = ↑ risk preeclampsia and seizures -monitor for headaches, visual disturbances, epigastric pain -rx: mag sulfate IV infusion

A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action? A. admin vit K B. dry the skin C. admin eye prophylaxis D. place an ID bracelet

B. dry the skin

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? A. mod lochia rubra B. fundus 3 fingerbreadths above the umbilicus C. mod swelling labia D. BP 130/84

B. fundus 3 fingerbreadths above the umbilicus -full bladder can raise level of uterine fundus

A nurse is providing teaching about newborn care to a client who is 2 hr postpartum. Which of the following statements by the client indicates a need for further teaching? A. i should keep my babys head covered B. my babys temp will be checked rectally Q hr C. i should place my baby on my stomach and cover her with a warm blanket D. my babys bassinet should be kept away from fans and AC

B. my babys temp will be checked rectally Q hr

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? A. bladder distension B. pulse C. RR D. color of lochia

B. pulse

A nurse is caring for a client who is 6 hr postpartum. The client is Rh-neg and her newborn is Rh-positive. The client asks why an indirect Coombs test was ordered by the provider. Which of the following is an appropriate response by the nurse? A. it determines if kernicterus will occur in newborn B. detects Rh-neg antibodies in newborns blood C. detects Rh-pos antibodies in moms blood D. determines presence of maternal antibodies in newborns blood

C. detects Rh-pos antibodies in moms blood -determines presence of Rh antibodies

A nurse is caring for a client who is 12 hr postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication? A. orthostatic hypotension B. fundus palpable at the umbilicus C. urine output 3,000 mL/12 hr D. HR 110

D. HR 110 -fluid volume depletion r/t hemorrhage

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? A. i'll let my baby drain one breast each feeding B. i'll try drinking an herbal tea to reduce the engorgement C. i'll apply cold compress 20 min before each feeding D. I'll feed baby Q 2 hrs

D. I'll feed baby Q 2 hrs -warm compress

12 hr postpartum and received spinal anesthesia for c/s

RR 10

3 days postpartum and breastfeeding

additional interventions are not indicated at this time

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) A. blot the perineal area dry after cleansing B. clean the perineal area from front to back C. perform hand hygiene before and after voiding D. apply ice packs to the perineal area several times a day E. wash the perineal area using a squeeze bottle of warm water after each void

A. blot the perineal area dry after cleansing B. clean the perineal area from front to back C. perform hand hygiene before and after voiding E. wash the perineal area using a squeeze bottle of warm water after each void -ice packs 24-48 hrs, doesnt pertain to infection

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 B. client who has preeclampsia with a BP 138/90 C. client who experienced a vaginal birth 24 hrs ago and reports no bleeding D. client who is scheduled for discharge following a laparoscopic tubal ligation

A. client who experienced a cesarean birth 4 hr ago and reports pain -maslows 138/90 = OK for preeclampitc pt

A nurse is caring for a client who had a vaginal delivery 2 hr ago. Which of the following actions should the nurse anticipate in the care of this client? (select all that apply) A. doc fundal height B. massage a firm fundus C. observe the lochia during palpation of fundus D. determine whether fundus is midline E. admin methylergonovine maleate if uterus is boggy

A. doc fundal height C. observe the lochia during palpation of fundus D. determine whether fundus is midline E. admin methylergonovine maleate if uterus is boggy

A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots in the pt perineal pad. The fundus is midline and firm at umbilicus. Which of the following actions should the nurse take? A. doc the findings and continue to monitor the pt B. notify the clients provider C. increase frequency of fundal massage D. encourage client to empty her bladder

A. doc the findings and continue to monitor the pt

A nurse is caring for a client who experienced a vagina birth 12 hr ago. The nurse recognizes the client is in the dependent, taking in phase of maternal postpartum adjustment. Which of the following findings should the nurse expect during this phase? A. expression of excitement B. lack of appetite C. focus on the family unit and its members D. eagerness to learn newborn care skills

A. expression of excitement

A nurse is caring for a client who is postpartum and receiving methylergonovine. Which of the following findings indicates that the med was effective? A. fundus firm to palpation B. increase in BP C. increase in lochia D. reports of absent breast pain

A. fundus firm to palpation

A nurse is caring for a client who experienced a c-section due to dysfunctional labor. The client states that she is disappointed that she did not have a natural birth. Which of the following responses should the nurse make? A. it sounds like you are feeling sad that things didn't go as planned B. at least you know you have a healthy baby C. maybe next time you can have a vaginal delivery D. you can resume sexual relations sooner than if you had delivered vaginally

A. it sounds like you are feeling sad that things didn't go as planned

A nurse is admitting a client who experienced a vaginal birth 2 hrs ago. The client is receiving an IV of LR w 25 units of oxytocin infusing and has large rubra lochia. VS: BP 146/94, HR 80, RR 18. The nurse reviews the Rx from the provider. Which of the following rx requires clarification? A. methylergonovine 0.2 mg IM now B. insert indwelling urinary cath C. admin O2 nonrebreather mask 5 L/min D. obtain lab study of pT and pTT

A. methylergonovine 0.2 mg IM now -contraindicated in BP over 140/90

A nurse is caring for a client who delivered a healthy term newborn via cesarean birth. The client asks the nurse, "is there a change that I could deliver my next baby without having a c/s?" Which of the following responses should the nurse provide? A. primary consideration is what type of incision was performed this time B. there are so many variables that you'll have to ask your obstetrician C. its too soon for you to be worrying about this now D. a repeat c/s is safer for both you and baby

A. primary consideration is what type of incision was performed this time

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? A. fundus soft, 1 cm to the R of umbilicus B. fundus firm, at level of umbilicus C. fundus present, to the L of umbilicus D. fundus soft, 2 cm above umbilicus

B. fundus firm, at level of umbilicus

A nurse is providing discharge teaching to a client who is 3 days postop following a cesarean birth. Which of the following client statements should indicate to the nurse teaching is effective? (select all that apply) A. i am likely to have a fever during the first week I am home B. i will resume taking my prenatal vitamins C. i will call my provider if I have discharge from my incision D. i should not have unrelieved pain in my abdomen E. i will rest in a recliner until my incision is healed

B. i will resume taking my prenatal vitamins C. i will call my provider if I have discharge from my incision D. i should not have unrelieved pain in my abdomen -encourage ambulation -may have elevated temp but not fever (>100.4)

A nurse is performing a physical exam of a client who is 1 day postpartum. Which of the following findings requires immediate intervention? A. decreased urge to void B. increased urine output C. displaced fundus from the midline D. fundal heigh below the umbilicus

C. displaced fundus from the midline

A nurse is caring for a client who is 7 days postpartum and calls the clinic to report pain and redness of her left calf. Besides seeing her provider, which of the following interventions should the nurse suggest? A. flex her knee while resting B. massage the area C. elevate her leg D apply cold compress

C. elevate her leg -encourage venous return to relieve pain -moist heat, never massage

A nurse is caring for a client who is 2 hr postop following a vaginal birth. Which of the following findings indicates the client's bladder is distended? A. pt reports frequent uterine contractions B. < 2.5 cm of rubra lochia on perineal pad C. fundus palpable to R of midline D. pt reports increased thirst

C. fundus palpable to R of midline

A nurse is caring for a client who experienced a vagina birth 3 hr ago. Upon palpation, the fundus is displaced to the R of the midline, is firm, and is 2 fingerbreadths above the umbilicus. Which of the following actions should the nurse complete at this time? A. massage the fundus B. insert urinary cath C. have the client urinate D. admin analgesic

C. have the client urinate

A nurse is caring for a client who is postpartum. The nurse should recognize which of the following statements by the client as an indication for inhibition of parental attachment? A. he's got my husbands nose, that's for sure B. i dont need a baby bath demonstration. I know how to do it C. i wish he had more hair. i will keep a hat on his head until he grows more D. do you think you could keep him in the nursery for the next feedings so i can get some sleep?

C. i wish he had more hair. i will keep a hat on his head until he grows more -shows disappointment in newborns appearance

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? A. assess client BP B. assess bladder for distension C. massage pt fundus D. prepare to admin prescribed oxytocic preparation

C. massage pt fundus

A nurse is assessing a client for postpartum infection. Which of the following findings should indicate to the nurse that the client requires further eval for endometritis? A. mod amount of dark red lochia with bloody odor B. localized area of breast tenderness C. pelvic pain D. hematuria

C. pelvic pain -foul smelling, profuse lochia -localized breast tenderness, fever and malaise = mastitis -hematuria = UTI

A nurse is preparing to admin methylergonovine IM to a client who experienced a vaginal deliver. The nurse should explain to the client that the purpose of this med is to prevent which of the following condition? A. postpartum infection B. hypertension C. postpartum hemorrhage D. thromboembolic events

C. postpartum hemorrhage -causes uterine contractions (oxytocic med)

A nurse is caring for a client who is postpartum and has a rx for Rho (D) immunoglobulin. The nurse should verify which of the following prior to administration? A. pt Rh pos and newborn is Rh neg B. pt Rh neg and newborn Rh neg C. pt Rh neg and newborn is Rh pos D. pt is Rh pos and newborn is Rh neg

C. pt Rh neg and newborn is Rh pos -admin prevents antibody formation in women who are Rh neg following exposure to Rh positive blood

A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn's maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make? A. there is no need to worry about that. most forms of hearing loss are not inherited B. look at how she looks at you when you speak. that is a good sign C. we do routine hearing screenings on newborns. you'll know the results before you leave the hospital D. the best way to determine if your baby can hear you is to clap your hands loudly and see if she startles

C. we do routine hearing screenings on newborns. you'll know the results before you leave the hospital

A nurse is planning care for a client who is 2 hour postpartum following a cesarean birth. The client has a hx of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care? A. apply warm, moist heat to clients lower extrem B. massage pt posterior lower legs C. place pillows under knees while resting in bed D. have client ambulate

D. have client ambulate

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 O2 via nonrebreather at 10 L/min which of the following actions should the nurse take next? A. insert indwelling urinary cath B. admin oxytocin by continuous IV C. tilt the client onto her R side with legs elevated at least 30 degrees D. massage clients fundus to promote contractions

D. massage clients fundus to promote contractions