postpartum ati
A nurse is caring for a client who is postpartum and non-lactating. The client reports breast pain. Which of the following statements should the nurse make
"Be sure to wear a well-fitted supportive bra."
A nurse is collecting data from a client who is postpartum. Which of the following findings should the nurse report to the provider
Report of blurred vision
A nurse is collecting data from a client who is 2 days postpartum. In which of the following locations should the nurse expect to locate the client's fundus
3 cm below the umbilicus
A nurse is collecting data from a client who is 1 day postpartum. Which of the following findings is a sign of a potential complication
Deep tendon reflexes 4+
A nurse is assisting with the plan of care for a client who is postpartum and has a history of a pulmonary embolus. The provider has prescribed heparin therapy prophylactically. Which of the following interventions should the nurse recommend to include in the plan
Monitor aPTT and platelet count
A nurse is collecting data from a postpartum client and observes a steady trickle of bright red blood from the client's vagina. The uterus is palpated as firm, midline, and located 1 cm below the umbilicus. Which of the following actions should the nurse take
Notify the provider
A nurse is caring for a client who is postpartum and reports that her episiotomy incision is pulling and stinging. Which of the following actions should the nurse take
Provide a sitz bath with warm water
A nurse assisting with the plan of care for a client who is postpartum. Which of the following strategies should the nurse include in the plan to prevent bladder distention
Run water in the sink while the client sits on the toilet
A nurse is evaluating a client who has just received instructions about breastfeeding. Which of the following statements should the nurse identify as an indication that the client understands how to prevent mastitis
"I should avoid waiting too long between feedings."
A nurse is reinforcing teaching about the rubella immunization with a client who is 24 hours postpartum. Which of the following client statements indicates an understanding of the teaching
"I should be careful to avoid becoming pregnant within the next month."
A nurse is reinforcing teaching with a postpartum client who is breastfeeding. Which of the following statements indicates an understanding of the teaching
"I should feed my baby 8 to 12 times a day, based on feeding cues."
A nurse is reinforcing with teaching a postpartum client about how to swaddle her newborn. Which of the following statements by the parent demonstrates an understanding of the teaching
"I should stop swaddling my baby once she is able to roll over by herself."
A nurse is reinforcing teaching about lactation suppression with a client whose newborn will be bottle-fed. Which of the following client statements indicates understanding of the teaching
"I should wear a support bra for a few days."
A nurse is caring for a client who is 6 hours postpartum following a dysfunctional labor. Which of the following statements by the client indicates a possible complication
"I think I have changed my pad every 15 minutes."
A nurse is providing postpartum discharge teaching for a client who is breastfeeding. The client states, "I've heard that I can't use any birth control until I stop breastfeeding." Which of the following responses should the nurse make
"A progestin-only pill or injection is available for use while you are breastfeeding."
A nurse is caring for a client who reports cramping while trying to breastfeed her newborn. Which of the following instructions should the nurse provide to the client
"Breastfeeding can cause uterine contractions."
A nurse is caring for a client who is 32 hours postpartum. The client reports nipple soreness and breast engorgement. Which of the following recommendations should the nurse provide
"Call me so I can check your baby's latch the next time you breastfeed."
A nurse is providing teaching to a client who is 1 hour postpartum about using the perineal squeeze bottle. Which of the following instructions should the nurse include
"Fill the perineal bottle with warm water prior to use."
A nurse is reinforcing teaching about breastfeeding with a client. Which of the following client statements indicates an understanding of the teaching
"I may notice increased cramping when I am feeding my baby."
A nurse is reinforcing teaching about mastitis with a client who is postpartum and breastfeeding her newborn. Which of the following statements by the client indicates an understanding of the teaching
"I will avoid any of my family members who are ill."
A nurse is providing postpartum discharge teaching about proper storage of breast milk for a client who is breastfeeding. Which of the following client statements indicates an understanding of the teaching
"I will discard any unused breastmilk that is left in the bottle."
A nurse is reinforcing discharge teaching with a postpartum client regarding elimination. Which of the following statements should the nurse include in the teaching
"Increase fluids to help prevent constipation."
A nurse is reinforcing teaching with a group of clients about pregnancy prevention during the postpartum period. Which of the following statements should the nurse include
"Lactating clients ovulate in their sixth month postpartum on average."
A nurse is reinforcing teaching with a client about using a disposable sitz bath. Which of the following instructions should the nurse include
"Loosen the tube clamp to regulate the rate of flow."
A nurse is reinforcing postpartum teachings with a client who is non-lactating about breast discomfort. Which of the following interventions should the nurse discuss with the client
"Place fresh cabbage leaves on your breasts."
A nurse on a postpartum unit is reinforcing teaching with a client about postpartum blues. Which of the following instructions should the nurse include
"Plan opportunities to get out of the house frequently."
A nurse is caring for a client who is 48 hours postpartum. The client expresses distress about her older children's acceptance of the new baby. Which of the following statements should the nurse make
"Present the older children with a small gift and say it is from the baby."
A nurse is reinforcing teaching with a postpartum client about the proper technique for performing Kegel exercises. Which of the following statements should the nurse make
"Pretend you are urinating and stop your urine stream intermittently."
A nurse is assisting with the care of a client who is 2 hours postpartum and is receiving an oxytocin IV. The client asks the nurse, "Why is there so little bleeding" Which of the following responses should the nurse make
"The bleeding is minimal until I discontinue your IV medication."
A postpartum nurse is caring for a client who reports excessive sweating during the first night after delivery. Which of the following statements should the nurse make
"This is a source of your fluid loss after delivery."
A nurse is reinforcing teaching with a client about postpartum fatigue. Which of the following statements should the nurse include
"Try to take naps when your infant is napping."
A nurse is reinforcing education about continuous heparin therapy with a client who is 18 hr postpartum and has developed a deep vein thrombosis (DVT). Which of the following statements should the nurse include in the teaching
"Use a soft toothbrush to gently brush your teeth."
A nurse is reinforcing teaching with a client who is breastfeeding about strategies to prevent mastitis. Which of the following instructions should the nurse include
"Use your finger to release suction after feeding."
The nurse is reinforcing teaching with a client who is postpartum about the rubella vaccine. Which of the followings statements should the nurse include
"You must not become pregnant for 28 days after receiving this immunization."
A nurse is reinforcing teaching with a client who has hemorrhoids following a vaginal birth. Which of the following statements should the nurse include in the teaching
"You should apply witch hazel after voiding or defecating."
A nurse is reinforcing discharge teaching with a client who is postpartum. Which of the following statements should the nurse make
"You should notify the provider immediately if either of your legs becomes swollen."
A nurse is reinforcing teaching to a client who is postpartum and has been prescribed warfarin therapy for a deep vein thrombosis. Which of the following instructions should the nurse include
"You will need to use a reliable form of contraception while on warfarin therapy."
A nurse is collecting data from a client 24 hr after delivery and notes the fundus is 2 cm above the umbilicus. Which of the following actions should the nurse take
Ambulate the client to the bathroom
A postpartum nurse is caring for a client who is 4 hours postpartum and has a painful third-degree perineal laceration. Which of the following interventions should the nurse take
Apply cold ice packs to the client's perineum
A nurse is collecting data from a client who is 12 hours postpartum. Which of the following locations should the nurse expect to palpate the client's fundus
Approximately 1 cm above the umbilicus
A nurse is preparing to massage the fundus of a client who is postpartum and experiencing uterine atony. Which of the following actions should the nurse plan to take when performing a fundal massage (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Ask the client to lie on her back with her knees flexed. Place a hand just above the client's symphysis pubis. Position a hand around the top of the client's fundus. Rotate the upper hand to massage the client's uterus. Use slight downward pressure to compress the client's fundus.
A nurse is collecting data from a client on the first postpartum day. Findings include a fundus that is firm and 1 fingerbreadth above and to the right of the umbilicus, moderate lochia rubra with small clots, temperature 37.3°C (99.2°F), and pulse rate 52/min. Which of the following actions should the nurse take
Ask the client when she last voided.
A nurse is caring for a client who is postpartum and reports abdominal pain due to flatus. Which of the following actions should the nurse take
Assist the client to ambulate in the hallway
A nurse is caring for a client who is postpartum and is having difficulty voiding. Which of the following actions should the nurse take first
Assist the client to the bathroom
A nurse is collecting data from a client who delivered vaginally 8 hours ago. The nurse notes that the client's fundus is 2 fingerbreadths above the umbilicus and has shifted to the left, and there is a large amount of lochia rubra on the perineal pad. Which of the following actions should the nurse take first
Assist the client to the toilet
A nurse is reinforcing discharge instructions with a client who had a cesarean birth 4 days ago. The client's hemoglobin level is 9.2 g/dL, and the provider has prescribed an iron supplement. Which of the following foods should the nurse recommend to help increase the client's iron intake
Citrus fruit
A nurse is assisting with the care of a client who is 2 hours postpartum and is exhibiting signs of hypovolemic shock. Which of the following actions should the nurse take
Elevate the client's legs to a 30° angle
A nurse is assisting with the care of a client who is postpartum and reports abdominal cramping. Which of the following actions should the nurse take
Encourage the client to interact with the newborn
A nurse is reinforcing teaching about manifestations of postpartum depression with a client. Which of the following findings should the nurse include
Episodes of irritability without justification
A nurse is collecting data from a client who is postpartum. The nurse should identify which of the following findings as a manifestation of endometritis
Foul-smelling lochia
A nurse is reviewing risk factors for postpartum depression with a newly licensed nurse. Which of the following risk factors should the nurse include
Gestational diabetes
A nurse is collecting data from a client who is postpartum. Which of the following findings should the nurse report to the provider
Headache
A nurse is caring for a client who is postpartum. The nurse should identify which of the following findings as a manifestation of a urinary tract infection
Hematuria
A nurse is caring for a client who is 3 days postpartum and has chosen to bottle feed the newborn. During examination of the client's breasts, the nurse notes that they are warm and firm. Which of the following actions should the nurse plan to take
Instruct the client to apply cold compresses.
A nurse is caring for a client who is 2 hours postpartum. The nurse notes that the client's perineal pad has a large amount of lochia rubra with several clots. Which of the following actions should the nurse take first
Massage the fundus
A nurse is assisting with the care of a client who is 8 hours postpartum and is experiencing hemorrhage. Which of the following actions should the nurse implement after notifying the provider (Select all that apply.)
Massage the fundus, Administer oxytocin with IV fluids, Insert an indwelling urinary catheter and Place the client in a lateral position with her legs elevated 30°
A nurse is collecting data from a client who is 3 days postpartum. When examining the client's uterus, which of the following techniques should the nurse use
Measure the height of the fundus in fingerbreadths in relation to the umbilicus
A nurse is caring for a client who is postpartum. The client suddenly appears restless and reports an inability to catch her breath. Which of the following actions should the nurse take
Notify the unit charge nurse and the rapid response team
A nurse is caring for a client who is postpartum and has endometritis. Which of the following findings should the nurse report to the provider
Oxygen saturation 93%
A provider is assisting with the care of a client who is postpartum following a vaginal delivery. The nurse should identify that which of the following circumstances is a risk factor for postpartum hemorrhage
Oxytocin-induced labor
A nurse is collecting data from a client who is 48 hours postpartum. Which of the following findings should the nurse report to the provider
Pelvic and uterine pain is present while at rest.
A nurse is reinforcing teaching with a client who is postpartum and has a hearing impairment. Which of the following techniques should the nurse use
Sit at the client's eye level
A nurse is collecting data from a client who is postpartum. Which of the following findings should the nurse report to the provider
The fundus feels soft and is a fingerbreadth below the umbilicus 72 hours after delivery.
A nurse is reinforcing teaching about the process of involution with a client who is postpartum. Which of the following pieces of information should the nurse provide
The fundus is not palpable abdominally at 2 weeks postpartum.
A nurse is collecting data from a client who is receiving morphine via patient-controlled analgesia (PCA) pump following a cesarean birth. Which of the following findings should the nurse report to the provider
Urine output 20 mL/hr
A nurse is reinforcing teaching about nutritional requirements during lactation for a client who is planning to breastfeed her newborn. Which of the following nutrients should nurse recommend the client increase during lactation
Vitamin C
A nurse is reinforcing teaching with a client who is postpartum and breastfeeding. Which of the following nutrients should the client increase her intake of while breastfeeding
Vitamin C
A nurse in an antepartum clinic is collecting data from a client who is 2 weeks postpartum and reports vaginal discharge. Which of the following discharge characteristics should the nurse expect
Yellowish-white uterine discharge
