Postpartum ATI quiz

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 let my baby drain one breast at each feeding" - "I'll try drinking an herbal tea to reduce the engorgement" - "I'll apply cold compresses 20 minutes before each feeding" - "I'll feed my baby every 2 hours"

"I'll feed my baby every 2 hours"

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). - Document fundal height - Massage a firm fundus - Observe the lochia during palpation of fundus - Determine whether the fundus is midline - Administer methylergonovine maleate if uterus is boggy

- Document fundal height - Observe the lochia during palpation of fundus - Determine whether the fundus is midline - Administer methylergonovine maleate if uterus is boggy

A nurse is caring for a client who experienced a vaginal 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? - Expressions of excitement - Lack of appetite - Focus on the family unit and its members - Eagerness to learn newborn care skills

Expressions of excitement

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 soft, 1 cm to the first of the umbilicus - Fundus firm, at level of the umbilicus - Fundus present, to the left of the umbilicus - Fundus soft, 2 cm above the umbilicus

Fundus firm, at the level of 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 - Assist the client on a bedpan to urinate - Prepare to administer oxytocic medication - Increase the client's fluid intake

Palpate the client's uterine fundus

A nurse is assessing a client who is 4 hr postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority? - Saturated perineal pad in 30 min - Deep tendon reflexes 4+ - Fundus at level of umbilicus

Deep tendon relfexes +4

A nurse is performing a physical examination of a client who is 1 day postpartum. Which of the following findings requires immediate intervention? - Decreased urge to void - Increased urine output - Displaced fundus from the midline - Fundal Height below the umbilicus

Displaced fundus from the midline

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 mmHg. Which of the following actions should the nurse take first? - Evaluate the firmness of the uterus - Initiate oxygen therapy by nonrebreather mask - Administer oxytocin infusion - Obtain a type and crossmatch

Evaluate the firmness of the uterus

A nurse is caring for a client who is 6 hr postpartum. The client if Rh-negative 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? - "It determines if kernicterus will occur in the newborn." - "It detects Rh-negative antibodies in the newborn's blood." - "It detects Rh-positive antibodies in the mother's blood." - "It determines the presence of maternal antibodies in the newborn's blood."

"It detects Rh-positive antibodies in the mother's blood."

A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the newborn's mouth, which of the following responses should the nurse make? - "You should place your nipple and some of the areola into her mouth" - "Babies know instinctively how much of the nipple to take into their mouth" - "Your baby's mouth is rather small so she will only take part of the nipple" - "Try to place the nipple, the areola, and some breast tissue beyond the areola into her mouth"

"You should place your nipple and some of the areola into her mouth"

A nurse is caring for a client who is 2 days postpartum, is breastfeeding, and reports nipple soreness. Which of the following measures should the nurse suggest to reduce discomfort during breastfeeding? (Select all that apply) - Apply breast milk to the nipples before each feeding - Place breast pads inside the nursing bra - Massage the breasts and nipples prior to feeding - Start breastfeeding with the nipple that is less sore - Change the infant's position on the nipples

- Apply breast milk to the nipples before each feeding - Start breastfeeding with the nipple that is less sore - Change the infant's position on the nipples

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? - Moderate lochia rubra - Fundus three fingerbreadths above the umbilicus - Moderate swelling of the labia - Blood pressure 130/84 mm Hg

Fundus three fingerbreadths above the umbilicus

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? - Encourage the client to perform Kegel exercises - Encourage the client to move to the left lateral position - Ask the client to rate her pain - Assist the client to the bathroom to void

Assist the client to the bathroom to void

A nurse is caring how 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 - 2 cm above the umbilicus - Once fingerbreadth above the symphysis pubis - To the right of the umbilicus

At the level of the umbilicus

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 the midline, is first, and is two fingerbreadths above the umbilicus. Which of the following actions should the nurse complete at this time? - Massage the fundus. - Insert a urinary catheter. - Have the client urinate. - Administer an analgesic.

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? - Within 2 days - In 3 to 5 days - In 6 to 8 days - In about 10 days

In 3 to 5 days

A nurse is teaching a client who is postpartum and has a new prescription for an injection of Rh0 (D) immunoglobulin. Which of the following should be included in the teaching? - It prevents the formation of Rh antibodies in mothers who are Rh negative. - It destroys Rh antibodies in mothers who are Rh negative. - It destroys Rh antibodies in newborns who are Rh positive. - It prevents the formation of Rh antibodies in newborns who are Rh positive.

It prevents the formation of Rh antibodies in mothers who are Rh negative.

A nurse is caring for a client who is 4 hr postpartum following a vaginal birth. The client has saturated perineal pad within 10 min. Which of the following actions should the nurse take first? - Assess client's blood pressure - Assess the bladder for distension - Massage the client's fundus - Prepare to administer a prescribed oxytocic preparation

Massage the client's fundus

A nurse us 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? - Insert an indwelling urinary catheter - Administer oxytocin by continuous IV infusion - Tilt the client onto her right side with her legs elevated to at least 30 degrees - Massage the client's fundus to promote contractions

Massage the client's fundus to promote contractions

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? - Bladder distension - Pulse rate - Respiratory rate - Color of lochia

Pulse rate