ATI-MN ATI Maternal Newborn Exam - Set 4 - Part 2

Correct Answer: Massage the fundus

Saturating a pad this quickly signals possible hemorrhage, and since uterine atony is the most common cause, the nurse massages the fundus first to firm the uterus. Option a is incorrect because documentation follows the immediate action to control the bleeding. Option b is incorrect because high Fowler does not control bleeding; firming the uterus is the priority. Option c is incorrect because offering food does nothing to address heavy bleeding.

Correct Answer: The bladder is empty

A full bladder prevents the uterus from contracting, so the nurse ensures the bladder is empty to help the uterus firm and the massage to be effective. Option a is incorrect because the client is positioned lying down for the assessment, not standing. Option b is incorrect because fasting has no role in managing uterine atony. Option d is incorrect because a darkened room does not affect uterine tone or bleeding.

Correct Answer: A rising heart rate

A rising heart rate with a falling blood pressure is the earliest sign of low blood volume, as the body speeds the heart to maintain circulation during blood loss. Option b is incorrect because blood pressure falls rather than rises as blood volume drops. Option c is incorrect because the skin becomes cool and clammy, not warm and flushed, with blood loss. Option d is incorrect because urine output decreases as the body conserves fluid during low volume.

Correct Answer: Blood pressure

Methylergonovine can raise blood pressure, so the nurse checks blood pressure first and withholds the medication if the client is hypertensive. Option a is incorrect because capillary refill does not guide whether this blood-pressure-raising medication is safe. Option b is incorrect because bowel sounds are not the safety concern with this uterotonic. Option c is incorrect because deep-tendon reflexes are monitored with magnesium sulfate, not this medication.

Correct Answer: Notify the provider and avoid massage

Unilateral calf pain with redness and warmth suggests a deep-vein thrombosis, so the nurse notifies the provider and avoids massaging the leg, which could dislodge a clot. Option a is incorrect because massaging the calf can dislodge a clot and cause a pulmonary embolism. Option b is incorrect because vigorous exercise of the affected leg can also dislodge a clot. Option d is incorrect because applying pressure to the calf does not treat a clot and risks dislodging it.

Correct Answer: Elevate the affected leg

Elevating the affected leg promotes venous return and reduces swelling, supporting treatment of a deep-vein thrombosis along with prescribed anticoagulants. Option a is incorrect because massaging the leg can dislodge the clot and is contraindicated. Option c is incorrect because prolonged sitting promotes venous stasis and clot formation. Option d is incorrect because keeping the leg dependent increases swelling and venous pooling.

Correct Answer: Protamine sulfate

Protamine sulfate is the antidote for heparin, so the nurse keeps it available to reverse bleeding caused by too much anticoagulation. Option b is incorrect because calcium gluconate is the antidote for magnesium sulfate. Option c is incorrect because vitamin K reverses warfarin, not heparin. Option d is incorrect because naloxone reverses opioids and has no effect on heparin.

Correct Answer: Elevate the head and give oxygen

Sudden shortness of breath and chest pain suggest a pulmonary embolism, so the nurse raises the head of the bed and gives oxygen to ease breathing while getting help. Option a is incorrect because massaging the legs can dislodge more clots and is unsafe. Option c is incorrect because lying flat makes breathing harder during a suspected embolism. Option d is incorrect because ambulation increases oxygen demand and can worsen the client's status.

Correct Answer: A hematoma

Severe localized pain and pressure with a bulging discolored area indicate a hematoma, where blood collects in the tissue, with pain rather than visible bleeding as the key clue. Option a is incorrect because afterpains are cramping from uterine contractions, not a bulging painful perineal mass. Option b is incorrect because engorgement involves the breasts, not the perineum. Option c is incorrect because uterine atony causes a boggy uterus and heavy bleeding, not localized perineal pressure.

Correct Answer: Stop the oxytocin infusion

With uterine inversion, the nurse stops any oxytocin first so the uterus can relax for the provider to reposition it, then resumes uterotonics afterward. Option a is incorrect because pushing does not correct an inversion and can increase harm. Option b is incorrect because fundal pressure can deepen the inversion rather than relieve it. Option d is incorrect because massaging or pressing on an inverted uterus worsens the inversion and bleeding.

Correct Answer: Retained placental fragments

Lochia that returns to bright red after fading suggests retained placental fragments, which keep the uterus from fully contracting and can cause continued bleeding. Option a is incorrect because a full bladder displaces the uterus but does not cause lochia to revert in color. Option b is incorrect because normal involution shows lochia fading over time, not returning to bright red. Option c is incorrect because mastitis is a breast infection and is unrelated to the color of lochia.

Correct Answer: Endometritis

Fever, uterine tenderness, and foul-smelling lochia together point to endometritis, an infection of the uterine lining that commonly begins a few days after birth. Option a is incorrect because a urinary tract infection causes burning and frequency rather than foul lochia and uterine tenderness. Option b is incorrect because deep-vein thrombosis causes leg pain and swelling, not foul-smelling lochia. Option d is incorrect because mastitis affects the breast with a tender red area, not the uterus and lochia.

Correct Answer: Continue breastfeeding frequently

Continuing to breastfeed frequently, especially on the affected side, keeps the breast emptied and helps resolve mastitis along with prescribed antibiotics. Option a is incorrect because the client needs generous fluids to support healing and milk supply. Option c is incorrect because tight binding traps milk and worsens the infection rather than draining it. Option d is incorrect because stopping breastfeeding lets milk pool and can lead to an abscess.

Correct Answer: Drink plenty of fluids each day

Drinking plenty of fluids dilutes urine and flushes the bladder, which helps prevent a urinary tract infection during the postpartum period. Option b is incorrect because limiting fluids concentrates urine and raises the risk of infection. Option c is incorrect because wiping back to front spreads bacteria toward the urethra and should be avoided. Option d is incorrect because delaying voiding allows urine to stagnate, which encourages bacterial growth.

Correct Answer: Redness with purulent drainage

A wound infection shows redness, warmth, tenderness, and purulent drainage, and the edges may separate, so these findings prompt treatment and wound care. Option a is incorrect because dry, intact edges indicate healing rather than an infected wound. Option b is incorrect because a pink, well-approximated incision describes normal healing, not infection. Option c is incorrect because an infected wound is usually tender, not free of tenderness.

Correct Answer: These feelings are common and usually pass

Postpartum blues are common and usually resolve within about ten days, so the nurse reassures the client while encouraging her to report feelings that persist or worsen. Option a is incorrect because hiding feelings can isolate the client; sharing them with support people is encouraged. Option c is incorrect because postpartum blues are a common, self-limiting reaction rather than a serious illness. Option d is incorrect because the blues typically resolve without long-term medication.

Correct Answer: Postpartum depression

Persistent sadness and loss of interest that do not resolve on their own suggest postpartum depression, which usually requires treatment rather than passing like the blues. Option a is incorrect because postpartum blues are brief and self-limiting, unlike these persistent symptoms. Option b is incorrect because ongoing, worsening sadness goes beyond normal adjustment to a newborn. Option d is incorrect because the taking-hold phase is a stage of learning newborn care, not a mood disorder.

Correct Answer: Ensure the safety of the client and newborn

When a client reports voices urging harm, ensuring the safety of both the client and the newborn is the priority, including close supervision and immediate provider involvement. Option b is incorrect because the provider must be contacted promptly, not after a delay, given the danger. Option c is incorrect because independent newborn care is unsafe when the client may harm the newborn. Option d is incorrect because dismissing the voices does not address the serious safety risk.

Correct Answer: Have you thought of harming yourself or baby

Asking directly about thoughts of self-harm or harming the newborn is the priority, because identifying this risk guides immediate safety measures and referral. Option a is incorrect because sleep is relevant but does not address the immediate safety concern of harm. Option c is incorrect because choosing a pediatrician is routine and unrelated to the urgent safety question. Option d is incorrect because home support matters but is not the priority over assessing for harm.

Correct Answer: Giving Rh immune globulin after birth

An Rh-negative client with an Rh-positive newborn receives Rh immune globulin within seventy-two hours of birth to prevent antibody formation that could affect a future pregnancy. Option b is incorrect because iron infusions address anemia, not Rh incompatibility. Option c is incorrect because Rh status does not require withholding vaccines. Option d is incorrect because an exchange transfusion treats severe newborn jaundice, not routine Rh prevention.