ATI MATERNAL HEALTH FINAL REAL EXAM 100
QUESTIONS WITH CORRECT ELABORATED
ANSWERS/ GRADED A+
The registered nurse is caring for a patient who had been administered an anesthetic
block during labor. For which risks should the registered nurse watch in the patient?
Select all that apply. -
ANS>>incomplete emptying of bladder bladder
distention
Urinary retention
Many women have difficulty with feeling the sensation to void after giving birth if they
have received an anesthetic block during labor, which inhibits neural functioning of the
bladder. This patient will be at risk for incomplete emptying, bladder distention, difficulty
voiding, and urinary retention. Ambulation difficulty and perineal lacerations are due to
episiotomy.
The registered nurse is used to working on the postpartum floor taking care of women
who have had normal vaginal births. Today, however, the registered nurse has been
assigned to help care for women who are less than 24 hours post cesarean birth. The
registered nurse realizes that some areas will not be assessed. What would the
registered nurse leave out of the patient assessments? - ANS>>perineum
Usually a woman who experiences cesarean birth does not have an episiotomy,
although rarely this may be the case.
Healthy bonding behaviors are important to note when the registered nurse is assessing
the new family. What would the registered nurse consider a warning sign that the
mother and infant were not attaching as they should? - ANS>>Mother states she
wanted a boy this time, not another girl.
It is important to differentiate between a new parent who is nervous and anxious about
her new role and one who is rejecting her parenting role. Warning signals of poor
attachment include turning away from the newborn, refusing or neglecting to provide
care, and disengagement from the newborn.
Which maternal reaction is the most concerning? - ANS>>She neglects to engage with or
provide care for the baby and shows little interest in it.
A mother not bonding with the infant or showing disinterest is a cause for concern and
requires a referral or notification of the primary health care provider. Some mothers
hesitate to take their newborn and express disappointment in the way the baby looks,
,Especially if they want a child of one sex and have a child of the opposite sex.
Expressing doubt about the ability to care for the baby is not unusual, and being tearful
for several days with difficulty eating and sleeping is common with "postpartum blues".
A mother just gave birth 3 hours ago. The registered nurse enters the room to continue
hourly assessments and finds the patient on the phone telling the listener about her fear
while driving to the hospital and not making it in time. The mother finishes the call, and
the registered nurse begins her assessment with which phrase? - ANS>>"It sounded like
you had quite a time getting here. Would you like to continue your story?"
The mother is going through the taking-in phase of relating events during her pregnancy
and birth. The registered nurse can facilitate this phase by allowing the mother to express
herself. Diverting the conversation, admonishing the mother, or warning of potential
problems does not accomplish this facilitation.
When planning the care for a patient during the first 24 hours postpartum, the registered
nurse expects to monitor the patient's pulse and blood pressure frequently based on the
understanding that the patient is at risk for which condition? - ANS>>hemorrhage
The registered nurse should monitor the pulse and blood pressure frequently in the first
24 hours postpartum because the patient is at greatest risk of hemorrhage.
Hemorrhoids cause discomfort and contribute to constipation; this does not call for
monitoring of pulse and blood pressure frequently. Increased coagulability causes
increased risk of thromboembolism in the puerperium. Precipitous labor or instrument-
assisted births pose an increased risk for cervical laceration. None of these conditions
require monitoring of pulse and blood pressure.
A patient in her sixth week postpartum reports general weakness. The patient has
stopped taking iron supplements that were prescribed to her during pregnancy. The
registered nurse would assess the patient for which condition? - ANS>>hypovolemia
The registered nurse should assess the patient for hypovolemia as the patient must
have had hemorrhage during birth and puerperium. Additionally, the patient also has
discontinued iron supplements. Hyperglycemia can be considered if the patient has a
history of diabetes. Hypertension and hyperthyroidism are not related to discontinuation
of iron supplements.
A woman has just given birth to a baby. Her prelabor vital signs were temperature: 98.8°
F (37.1° C); blood pressure: 120/70 mm Hg; pulse; 80 beats/min. and respirations: 20
breaths/min. Which combination of findings during the early postpartum period are the
most concerning? - ANS>>blood pressure 90/50 mm Hg, pulse 120 beats/min,
respirations 24 breaths/min.
The decrease in BP with an increase in HR and RR indicate a potential significant
complication and are out of the range of normals from birth and need to be reported
immediately. Shaking chills with a temperature of 100.3º F (37.9º C) can occur due to
, stress on the body and is considered a normal finding. A fever of 100.4º F (38º C)
should be reported. The other options are considered to be within normal limits after
giving birth to a baby.
A woman who gave birth to a healthy baby 5 days ago is experiencing fatigue and
weepiness, lasting for short periods each day. Which condition does the registered nurse
believe is causing this experience? - ANS>>postpartum baby blues
Postpartum baby blues is common in women after giving birth. It is a mild depression;
however, functioning usually is not impaired. Postpartum blues usually peaks at day 4
or 5 after birth. Postpartum anxiety and postpartum depression do not usually start until
at least 3 to 4 weeks and up to 1 year following the birth of a baby. Postpartum reaction
is a term to include postpartum depression, anxiety, and psychosis.
The registered nurse is caring for a patient who had been administered an anesthetic
block during labor. For which risks should the registered nurse watch in the patient?
Select all that apply -
ANS>>incomplete emptying of bladder bladder
distention
urinary retention
Many women have difficulty with feeling the sensation to void after giving birth if they
have received an anesthetic block during labor, which inhibits neural functioning of the
bladder. This patient will be at risk for incomplete emptying, bladder distention, difficulty
voiding, and urinary retention. Ambulation difficulty and perineal lacerations are due to
episiotomy.
Which lochia pattern should be reported immediately? - ANS>>moderate lochia serosa
on day 4 postpartum, increasing in volume and changing to rubra on day 5
Lochia by day 4 should be decreasing in amount, and the color should be changing to
pink tinge. Red rubra on day 4 may indicate bleeding, and the healthcare provider
should be notified. A moderate flow of lochia rubra on day 3 postpartum, changing to
serosa on day 5, is a normal finding; as is lochia progressing from rubra to serosa to
alba within 10 days of delivery; and so is moderate lochia rubra on day 3, mixed serosa
and rubra on day 4, and light serosa on day 5.
A patient has just given birth to her second child and will breastfeed. Although she
wants "lots of kids," she does not want to become pregnant again until her second child
is at least 2 years old. The registered nurse would counsel her to start using birth control
at what point?
- ANS>>as soon as she resumes sexual activity
She can ovulate even though she is not having a normal menstrual cycle. She needs to
take precautions. Beginning to use birth control within 6 weeks, or within 18 months, or
as soon as she stops breastfeeding is not affording her protection from getting
pregnant. She should use mechanical means of birth control as soon as she resumes
sexual activity.
QUESTIONS WITH CORRECT ELABORATED
ANSWERS/ GRADED A+
The registered nurse is caring for a patient who had been administered an anesthetic
block during labor. For which risks should the registered nurse watch in the patient?
Select all that apply. -
ANS>>incomplete emptying of bladder bladder
distention
Urinary retention
Many women have difficulty with feeling the sensation to void after giving birth if they
have received an anesthetic block during labor, which inhibits neural functioning of the
bladder. This patient will be at risk for incomplete emptying, bladder distention, difficulty
voiding, and urinary retention. Ambulation difficulty and perineal lacerations are due to
episiotomy.
The registered nurse is used to working on the postpartum floor taking care of women
who have had normal vaginal births. Today, however, the registered nurse has been
assigned to help care for women who are less than 24 hours post cesarean birth. The
registered nurse realizes that some areas will not be assessed. What would the
registered nurse leave out of the patient assessments? - ANS>>perineum
Usually a woman who experiences cesarean birth does not have an episiotomy,
although rarely this may be the case.
Healthy bonding behaviors are important to note when the registered nurse is assessing
the new family. What would the registered nurse consider a warning sign that the
mother and infant were not attaching as they should? - ANS>>Mother states she
wanted a boy this time, not another girl.
It is important to differentiate between a new parent who is nervous and anxious about
her new role and one who is rejecting her parenting role. Warning signals of poor
attachment include turning away from the newborn, refusing or neglecting to provide
care, and disengagement from the newborn.
Which maternal reaction is the most concerning? - ANS>>She neglects to engage with or
provide care for the baby and shows little interest in it.
A mother not bonding with the infant or showing disinterest is a cause for concern and
requires a referral or notification of the primary health care provider. Some mothers
hesitate to take their newborn and express disappointment in the way the baby looks,
,Especially if they want a child of one sex and have a child of the opposite sex.
Expressing doubt about the ability to care for the baby is not unusual, and being tearful
for several days with difficulty eating and sleeping is common with "postpartum blues".
A mother just gave birth 3 hours ago. The registered nurse enters the room to continue
hourly assessments and finds the patient on the phone telling the listener about her fear
while driving to the hospital and not making it in time. The mother finishes the call, and
the registered nurse begins her assessment with which phrase? - ANS>>"It sounded like
you had quite a time getting here. Would you like to continue your story?"
The mother is going through the taking-in phase of relating events during her pregnancy
and birth. The registered nurse can facilitate this phase by allowing the mother to express
herself. Diverting the conversation, admonishing the mother, or warning of potential
problems does not accomplish this facilitation.
When planning the care for a patient during the first 24 hours postpartum, the registered
nurse expects to monitor the patient's pulse and blood pressure frequently based on the
understanding that the patient is at risk for which condition? - ANS>>hemorrhage
The registered nurse should monitor the pulse and blood pressure frequently in the first
24 hours postpartum because the patient is at greatest risk of hemorrhage.
Hemorrhoids cause discomfort and contribute to constipation; this does not call for
monitoring of pulse and blood pressure frequently. Increased coagulability causes
increased risk of thromboembolism in the puerperium. Precipitous labor or instrument-
assisted births pose an increased risk for cervical laceration. None of these conditions
require monitoring of pulse and blood pressure.
A patient in her sixth week postpartum reports general weakness. The patient has
stopped taking iron supplements that were prescribed to her during pregnancy. The
registered nurse would assess the patient for which condition? - ANS>>hypovolemia
The registered nurse should assess the patient for hypovolemia as the patient must
have had hemorrhage during birth and puerperium. Additionally, the patient also has
discontinued iron supplements. Hyperglycemia can be considered if the patient has a
history of diabetes. Hypertension and hyperthyroidism are not related to discontinuation
of iron supplements.
A woman has just given birth to a baby. Her prelabor vital signs were temperature: 98.8°
F (37.1° C); blood pressure: 120/70 mm Hg; pulse; 80 beats/min. and respirations: 20
breaths/min. Which combination of findings during the early postpartum period are the
most concerning? - ANS>>blood pressure 90/50 mm Hg, pulse 120 beats/min,
respirations 24 breaths/min.
The decrease in BP with an increase in HR and RR indicate a potential significant
complication and are out of the range of normals from birth and need to be reported
immediately. Shaking chills with a temperature of 100.3º F (37.9º C) can occur due to
, stress on the body and is considered a normal finding. A fever of 100.4º F (38º C)
should be reported. The other options are considered to be within normal limits after
giving birth to a baby.
A woman who gave birth to a healthy baby 5 days ago is experiencing fatigue and
weepiness, lasting for short periods each day. Which condition does the registered nurse
believe is causing this experience? - ANS>>postpartum baby blues
Postpartum baby blues is common in women after giving birth. It is a mild depression;
however, functioning usually is not impaired. Postpartum blues usually peaks at day 4
or 5 after birth. Postpartum anxiety and postpartum depression do not usually start until
at least 3 to 4 weeks and up to 1 year following the birth of a baby. Postpartum reaction
is a term to include postpartum depression, anxiety, and psychosis.
The registered nurse is caring for a patient who had been administered an anesthetic
block during labor. For which risks should the registered nurse watch in the patient?
Select all that apply -
ANS>>incomplete emptying of bladder bladder
distention
urinary retention
Many women have difficulty with feeling the sensation to void after giving birth if they
have received an anesthetic block during labor, which inhibits neural functioning of the
bladder. This patient will be at risk for incomplete emptying, bladder distention, difficulty
voiding, and urinary retention. Ambulation difficulty and perineal lacerations are due to
episiotomy.
Which lochia pattern should be reported immediately? - ANS>>moderate lochia serosa
on day 4 postpartum, increasing in volume and changing to rubra on day 5
Lochia by day 4 should be decreasing in amount, and the color should be changing to
pink tinge. Red rubra on day 4 may indicate bleeding, and the healthcare provider
should be notified. A moderate flow of lochia rubra on day 3 postpartum, changing to
serosa on day 5, is a normal finding; as is lochia progressing from rubra to serosa to
alba within 10 days of delivery; and so is moderate lochia rubra on day 3, mixed serosa
and rubra on day 4, and light serosa on day 5.
A patient has just given birth to her second child and will breastfeed. Although she
wants "lots of kids," she does not want to become pregnant again until her second child
is at least 2 years old. The registered nurse would counsel her to start using birth control
at what point?
- ANS>>as soon as she resumes sexual activity
She can ovulate even though she is not having a normal menstrual cycle. She needs to
take precautions. Beginning to use birth control within 6 weeks, or within 18 months, or
as soon as she stops breastfeeding is not affording her protection from getting
pregnant. She should use mechanical means of birth control as soon as she resumes
sexual activity.
