ATI POSTPARTUM ( UPDATED 2024 )
COMPLETE QUESTIONS & ANSWERS (SOLVED) 100% CORRECT
1. What physical changes can be seen in the breasts postpartum?: secretion of colostrum,
which occurs during pregnancy and 2-3 days immediately after birth. Milk is produced 2-3
days after the delivery of the newborn.
2. How should a nurse assess the breasts postpartum?:
a - Colostrum secretion in lactating and nonlactating pt's
b - engorgement of the breast tissue as a result of lymphatic circulation, milkproduction, and
temporary vein congestion
c - redness and tenderness of the breast
d - cracked nipples and indications of mastitis (infection in a milk duct of the breastwith
concurrent flu-like symptoms)
e - ascertain that the newborn who is breastfeeding has latched on correctly toprevent sore
nipples
f - ineffective newborn feeding patterns r/t maternal dehydration, maternal discom-fort
newborn positioning, or difficulty with the newborn latching onto the breast
3. What are the nursing interventions r/t breasts and breastfeeding?:
a - encourage early demand breastfeeding for the pt who is lactating, which will also stimulate
the production of natural oxytocin and help prevent uterine hemorrhage
b - assist the pt into a comfortable position, and have her try various positions during
breastfeeding (cradle hold, side-lying, and football hold). Explain how varyingpositions can
prevent nipple soreness
c - teach the pt the importance of proper latch techniques (the newborn takes in partof the areola
and nipple, not just the tip of the nipple) to prevent nipple soreness
d - inform the pt that breastfeeding causes the release of oxytocin, which stimulatesuterine
contractions. This is a normal occurrence and beneficial to uterine tone
4. What are the physical cardiovascular changes during postpartum?:
a - decrease in blood volume r/t blood loss during childbirth (average blood loss is 500mL in
uncomplicated vaginal birth and 1000 mL for c-section) and diaphoresis anddiuresis of the
excess fluid accumulated during the last part of the pregnancy. Lossoccurs within the first 2-3
days post delivery
b - hypovolemic shock does not usually occur in response to the normal blood loss of labor
and birth because of the expanded blood volume of pregnancy and the readjustment in the
maternal vasculature, which occurs in response to the following:elimination of the placenta,
diverting 500-750 mL of blood into the maternal systemiccirculation and rapid reduction in the
size of the uterus, putting more blood into thematernal systemic circulation
5. What are the physical changes in blood values, coagulation factors, and fibrinogen levels
during the puerperium?: 1) increased Hct/Hgb values are pre-sent immediately after delivery
for up to 72 hrs. Leukocytosis (WBC elevation) of up to 20,000-25,000/mm3 occurs for the
, first 10-14 days without the presence of
infection and then returns to normal
2) coagulation factors and fibrinogen levels increase during pregnancy and remain elevated for
2-3 weeks postpartum. Hypercoagulability predisposes the postpartum client to thrombus
formation and thromboembolism
6. What are the physical changes to vital signs?: 1) BP is usually unchangedwith an
uncomplicated pregnancy but may have an insignificant, slight transient increase
2) Possible orthostatic hypotension within the first 48 hr postpartum may occur immediately
after standing up with feelings of faintness or dizziness resulting fromsplanchnic
(viscera/internal organs) engorgement that can occur after birth
3) Elevation of pulse, stroke volume and cardiac output for the first hour postpartumoccurs and
then gradually decreases to a prepregnant state baseline by 8-10 weeks
4) Elevation of temperature 38 C (100 F) resulting from dehydration after labor duringthe first 24
hr may occur, but should return to normal after 24 hr postpartum
7. What should the nurse assess for regarding vascularity?: assess for cardio- vascular and vital
sign changes and monitor blood component changes. Also inspect the pt's legs for redness,
swelling, and warmth which are additional signs of venousthrombosis
8. What are interventions regarding alterations in findings?: 1) notify the provider and
perform prescribed interventions based on the cause of the alteration
2) encourage early ambulation to prevent venous stasis and thrombosis
3) apply anti-embolism hose to the client's lower extremities if she is at high risk for
developing venous stasis and thrombosis. The hose should be removed as soon as the pt is
ambulating
4) administer medications as prescribed
9. What are the physical changes in the GI tract?: 1) an increased appetitefollowing delivery
2) constipation with bowel evacuation delayed until 2-3 days after birth
3) hemorrhoids
10. What are the GI assessments?: 1) reports of hunger, nurse should expect ptto have a good
appetite
2) bowel sounds and function and the return of normal bowel function
3) rectal area for varicosities (hemorrhoids)
4) operative vaginal birth (forceps-assisted and vacuum-assisted) and anal sphincter
lacerations increase the risk of temporary postpartum anal incontinence that usually resolves
within 6 months
11. What are the nursing interventions for GI tract?: 1) encourage the pt to take measures to
soften her stools and promote bowel function (early ambulation,increased fluids, and high-
fiber food sources)
COMPLETE QUESTIONS & ANSWERS (SOLVED) 100% CORRECT
1. What physical changes can be seen in the breasts postpartum?: secretion of colostrum,
which occurs during pregnancy and 2-3 days immediately after birth. Milk is produced 2-3
days after the delivery of the newborn.
2. How should a nurse assess the breasts postpartum?:
a - Colostrum secretion in lactating and nonlactating pt's
b - engorgement of the breast tissue as a result of lymphatic circulation, milkproduction, and
temporary vein congestion
c - redness and tenderness of the breast
d - cracked nipples and indications of mastitis (infection in a milk duct of the breastwith
concurrent flu-like symptoms)
e - ascertain that the newborn who is breastfeeding has latched on correctly toprevent sore
nipples
f - ineffective newborn feeding patterns r/t maternal dehydration, maternal discom-fort
newborn positioning, or difficulty with the newborn latching onto the breast
3. What are the nursing interventions r/t breasts and breastfeeding?:
a - encourage early demand breastfeeding for the pt who is lactating, which will also stimulate
the production of natural oxytocin and help prevent uterine hemorrhage
b - assist the pt into a comfortable position, and have her try various positions during
breastfeeding (cradle hold, side-lying, and football hold). Explain how varyingpositions can
prevent nipple soreness
c - teach the pt the importance of proper latch techniques (the newborn takes in partof the areola
and nipple, not just the tip of the nipple) to prevent nipple soreness
d - inform the pt that breastfeeding causes the release of oxytocin, which stimulatesuterine
contractions. This is a normal occurrence and beneficial to uterine tone
4. What are the physical cardiovascular changes during postpartum?:
a - decrease in blood volume r/t blood loss during childbirth (average blood loss is 500mL in
uncomplicated vaginal birth and 1000 mL for c-section) and diaphoresis anddiuresis of the
excess fluid accumulated during the last part of the pregnancy. Lossoccurs within the first 2-3
days post delivery
b - hypovolemic shock does not usually occur in response to the normal blood loss of labor
and birth because of the expanded blood volume of pregnancy and the readjustment in the
maternal vasculature, which occurs in response to the following:elimination of the placenta,
diverting 500-750 mL of blood into the maternal systemiccirculation and rapid reduction in the
size of the uterus, putting more blood into thematernal systemic circulation
5. What are the physical changes in blood values, coagulation factors, and fibrinogen levels
during the puerperium?: 1) increased Hct/Hgb values are pre-sent immediately after delivery
for up to 72 hrs. Leukocytosis (WBC elevation) of up to 20,000-25,000/mm3 occurs for the
, first 10-14 days without the presence of
infection and then returns to normal
2) coagulation factors and fibrinogen levels increase during pregnancy and remain elevated for
2-3 weeks postpartum. Hypercoagulability predisposes the postpartum client to thrombus
formation and thromboembolism
6. What are the physical changes to vital signs?: 1) BP is usually unchangedwith an
uncomplicated pregnancy but may have an insignificant, slight transient increase
2) Possible orthostatic hypotension within the first 48 hr postpartum may occur immediately
after standing up with feelings of faintness or dizziness resulting fromsplanchnic
(viscera/internal organs) engorgement that can occur after birth
3) Elevation of pulse, stroke volume and cardiac output for the first hour postpartumoccurs and
then gradually decreases to a prepregnant state baseline by 8-10 weeks
4) Elevation of temperature 38 C (100 F) resulting from dehydration after labor duringthe first 24
hr may occur, but should return to normal after 24 hr postpartum
7. What should the nurse assess for regarding vascularity?: assess for cardio- vascular and vital
sign changes and monitor blood component changes. Also inspect the pt's legs for redness,
swelling, and warmth which are additional signs of venousthrombosis
8. What are interventions regarding alterations in findings?: 1) notify the provider and
perform prescribed interventions based on the cause of the alteration
2) encourage early ambulation to prevent venous stasis and thrombosis
3) apply anti-embolism hose to the client's lower extremities if she is at high risk for
developing venous stasis and thrombosis. The hose should be removed as soon as the pt is
ambulating
4) administer medications as prescribed
9. What are the physical changes in the GI tract?: 1) an increased appetitefollowing delivery
2) constipation with bowel evacuation delayed until 2-3 days after birth
3) hemorrhoids
10. What are the GI assessments?: 1) reports of hunger, nurse should expect ptto have a good
appetite
2) bowel sounds and function and the return of normal bowel function
3) rectal area for varicosities (hemorrhoids)
4) operative vaginal birth (forceps-assisted and vacuum-assisted) and anal sphincter
lacerations increase the risk of temporary postpartum anal incontinence that usually resolves
within 6 months
11. What are the nursing interventions for GI tract?: 1) encourage the pt to take measures to
soften her stools and promote bowel function (early ambulation,increased fluids, and high-
fiber food sources)
