ATI NURSING TESTBANK 2024 POSTPARTUM AND NEWBORN<\/p>\n\n\n\n
The nurse is conducting a prenatal class explaining the various activities that will occur within the first
few hours after birth. The nurse determines the session is successful when the couples correctly
choose which reason for the use of an antibiotic ointment.
A Prevent infection of the umbilical cord
B Prevent infection of the eyes from vaginal bacteria
C Protect tear ducts from vaginal bacteria
D Protect the urethra from fecal material
Correct Answer: B
Prevent infection of the eyes from vaginal bacteria. This is because some newborns can be exposed to
bacteria such as gonorrhea or chlamydia during delivery, which can cause a serious eye infection called
gonococcal ophthalmia neonatorum (GON). Applying an antibiotic ointment such as erythromycin or
ilotycin can prevent GON and other less severe eye infections by killing the bacteria.
Choice A is not correct because the umbilical cord does not need antibiotic ointment to prevent
infection. It should be kept clean and dry until it falls off naturally.
Choice C is not correct because the tear ducts are not affected by vaginal bacteria. They are small tubes
that drain tears from the eyes to the nose.
Choice D is not correct because the urethra is not a common site of infection for newborns. The urethra
is the tube that carries urine from the bladder to the outside of the body.
A nurse is caring for a postpartum client who saturates a perineal pad in 10 minutes. Which of the
following actions should the nurse take first?
A Administer oxytocin.
B Observe for pooling of blood under the buttocks.
C Check the client’s blood pressure.
D Massage the client’s fundus.<\/p>\n\n\n\n
Correct Answer: D
Massage the client\u2019s fundus. This is because the most common cause of postpartum hemorrhage is
uterine atony, which is the failure of the uterus to contract after delivery. Massaging the fundus can
stimulate uterine contractions and reduce bleeding by compressing the blood vessels at the placental
site.
Choice A is not correct because administering oxytocin is not the first action to take. Oxytocin is a
medication that can also help the uterus contract, but it should be given after assessing the uterine tone
and bleeding.
Choice B is not correct because observing for pooling of blood under the buttocks is not a priority action.
It can help estimate the amount of blood loss, but it does not address the cause of bleeding or stop it.
Choice C is not correct because checking the client\u2019s blood pressure is not the first action to take. Blood
pressure can indicate hypovolemia due to blood loss, but it is not a sensitive indicator and may remain
normal until a significant amount of blood is lost.
The nurse assesses a postpartum woman’s perineum and notices that her lochial discharge is
moderate in amount and red. The nurse would record this as what type of lochia?
A Lochia alba
B Lochia normal
C Lochia serosa
D Lochia rubra
Correct Answer: D
This is because lochia rubra is the first stage of lochia, the vaginal discharge after giving birth. It
comprises blood, shreds of fetal membranes, decidua, vernix caseosa, lanugo, and membranes. It is red
in color because of the large amount of blood it contains. It lasts 1 to 4 days after birth.
Choice A is not correct because lochia alba is the last stage of lochia. It is whitish or yellowish-white in
color and contains fewer red blood cells and more leukocytes, epithelial cells, cholesterol, fat, mucus,
and microorganisms. It lasts from the second through the third to sixth weeks after delivery.
Choice B is not correct because there is no such thing as lochia normal. Lochia has three stages: lochia
rubra, lochia serosa and lochia alba.
Choice C is not correct because lochia serosa is the second stage of lochia. It is brownish or pink in color
and contains serous exudate, erythrocytes, leukocytes, cervical mucus, and microorganisms. It lasts for 4
to 12 days after delivery.<\/p>\n\n\n\n
A nurse is collecting data from a client who delivered 2 hours ago. The client has moderate lochia
rubra, temperature within normal limits, breasts soft, fundus firm, slightly deviated to the right, pulse
rate 88\/min, respiratory rate 18\/min.
Which of the following actions should the nurse perform?
A Encourage the client to nurse more frequently so her milk will come in
B Report the client’s temperature elevation
C Ask the client to empty her bladder
D Increase IV fluids
Correct Answer: C
ask the client to empty her bladder. A full bladder can cause the uterus to be displaced and lead to
excessive bleeding. The moderate lochia rubra, normal temperature, soft breasts, firm fundus, slightly
deviated to the right, pulse rate of 88\/min, and respiratory rate of 18\/min are all normal findings.
Choice A is not correct because the client’s milk will come in regardless of nursing frequency.
Choice B is not correct because the client’s temperature is within normal limits.
Choice D is not correct because there is no indication of an increase in IV fluids.
To protect newborns from infection while in the nursery, the nurse plans to:
A Adjust room temperature between 75\u00b0F and 80\u00b0F
B Wear a disposable gown when giving infant care
C Keep the newborn dressed warmly
D Wash hands before touching each baby
Correct Answer: D
Wash hands before touching each baby. This is because hand hygiene is the most effective way to
prevent infection transmission in the nursery. Hand hygiene should be performed before and after every
patient contact, as well as before and after wearing gloves or handling equipment. Hand hygiene can be
done by washing hands with soap and water or using alcohol-based hand rubs.
Choice A is not correct because adjusting room temperature between 75\u00b0F and 80\u00b0F is not a measure to
protect newborns from infection. The room temperature should be maintained within a comfortable
range for newborns, but it does not affect infection risk<\/p>\n\n\n\n