ATI-MN ATI Maternal Newborn Exam - Set 4 - Part 1

Correct Answer: Massage the fundus

A boggy fundus means the uterus is not contracting well, so the nurse massages it first to firm the uterus and prevent hemorrhage. Option b is incorrect because the nurse first corrects the boggy fundus at the bedside with massage before notifying the provider. Option c is incorrect because oral fluids do not firm the uterus, and the immediate concern is uterine tone. Option d is incorrect because documenting comes after acting on a boggy fundus that could lead to bleeding.

Correct Answer: Assist the client to void

A firm fundus displaced upward and to the side usually means a full bladder, so the nurse assists the client to void to allow the uterus to return to midline. Option a is incorrect because lowering the bed does not empty the bladder that is displacing the uterus. Option b is incorrect because the fundus is already firm, so vigorous massage is unnecessary and would not fix the displacement. Option c is incorrect because a uterotonic addresses a boggy uterus, not displacement caused by a full bladder.

Correct Answer: Fundus about one centimeter below the umbilicus

The uterus descends roughly one fingerbreadth per day after birth, so by the first day the fundus is expected to be about one centimeter below the umbilicus. Option b is incorrect because the fundus is still palpable in the early postpartum period and becomes unpalpable only later. Option c is incorrect because a boggy, displaced fundus is an abnormal finding that signals atony or a full bladder. Option d is incorrect because a fundus rising above the umbilicus suggests a full bladder or poor tone, not normal involution.

Correct Answer: Support the lower uterus while palpating

The nurse teaches the client to support the lower uterus with one hand while palpating the fundus, which protects the uterus from inversion during assessment. Option a is incorrect because deep pressure with both fists is not the technique and can cause harm. Option b is incorrect because palpating without supporting the lower uterus risks inverting the uterus, which can cause severe bleeding. Option d is incorrect because a full bladder displaces the uterus, so the client should empty the bladder before assessing.

Correct Answer: Lochia color, amount, and odor

Lochia color, amount, and odor are part of the routine postpartum assessment, which also includes the breasts, uterus, bowel, bladder, and perineum. Option a is incorrect because amniotic fluid is assessed during labor and birth, not after the newborn is delivered. Option b is incorrect because cervical dilation is monitored during labor, not as part of postpartum care. Option c is incorrect because the fetal heart rate is assessed before birth, not during the postpartum period.

Correct Answer: Dark red discharge

On the first few days after birth, lochia rubra is dark red as the uterus sheds blood and tissue, which is the expected finding at this stage. Option b is incorrect because large clots passed frequently suggest excessive bleeding and are not expected. Option c is incorrect because yellowish-white lochia alba appears later, around ten days, not on the second day. Option d is incorrect because a foul odor suggests infection rather than the normal smell of early lochia.

Correct Answer: A genital tract laceration

Bright red bleeding that continues while the fundus stays firm suggests a laceration of the birth canal rather than atony, so the source must be located and repaired. Option a is incorrect because normal lochia trickles but does not flow steadily as bright red blood with a firm uterus. Option b is incorrect because a full bladder displaces the fundus but does not cause a steady flow of bright red blood. Option d is incorrect because uterine atony produces a boggy fundus, whereas this client's fundus is firm.

Correct Answer: Encourage fluids and reassess

A temperature up to this level in the first day after birth often reflects dehydration, so the nurse encourages fluids and reassesses before assuming infection. Option b is incorrect because a mildly elevated temperature in the first day is commonly from dehydration and does not require immediate notification. Option c is incorrect because antibiotics are not started for a single early temperature that is likely from fluid loss. Option d is incorrect because a cooling blanket is excessive for a mild, expected early elevation.

Correct Answer: It is an expected finding

A slow heart rate is a common, expected finding in the early postpartum period as the body adjusts after birth, so it does not require intervention. Option a is incorrect because an expected slow heart rate without other symptoms does not call for oxygen. Option b is incorrect because hemorrhage causes a rising heart rate with falling blood pressure, not a slow heart rate. Option d is incorrect because infection typically raises the heart rate and temperature rather than lowering the rate.

Correct Answer: It can be a normal postpartum change

A rise in white blood cells is a normal postpartum change that helps protect against infection and supports healing, so it is not automatically a sign of illness. Option a is incorrect because the white blood cell count reflects immune activity, not the red cell measure used for anemia. Option b is incorrect because the elevation is expected after birth and does not by itself confirm an infection. Option c is incorrect because a normal postpartum rise in white cells does not require isolation.

Correct Answer: Have the client sit before standing

Orthostatic hypotension is common in the early postpartum period, so the nurse teaches the client to sit first before standing to prevent dizziness and falls. Option a is incorrect because restricting fluids would worsen low blood pressure and dizziness. Option b is incorrect because remaining flat all day is unnecessary and increases the risk of clots from immobility. Option d is incorrect because this dizziness is a common, expected change rather than an abnormal finding.

Correct Answer: Focusing on her own needs and the birth

In the taking-in phase, the client focuses on her own needs and often wants to talk about the birth, relying on others before she moves toward newborn care. Option a is incorrect because focusing on the family as a unit describes the letting-go phase that comes later. Option c is incorrect because refusing to hold the newborn is a sign of impaired bonding, not a normal taking-in behavior. Option d is incorrect because confidently taking charge of care reflects the later taking-hold phase, not taking-in.

Correct Answer: Holding the newborn face-to-face

Holding the newborn face-to-face with eye contact is a positive bonding behavior, showing the client is engaging with and claiming her newborn. Option b is incorrect because avoiding eye contact is a warning sign of difficulty bonding. Option c is incorrect because declining to name the newborn can signal weak attachment, not healthy bonding. Option d is incorrect because turning away from the newborn suggests impaired rather than positive bonding.

Correct Answer: Teach and let the client practice newborn care

During taking-hold the client is ready to learn, so the nurse teaches newborn care and allows the client to practice while offering encouragement and acceptance. Option a is incorrect because the client is eager to learn, so questions should be welcomed rather than discouraged. Option b is incorrect because making all decisions removes the independence the client is developing during this phase. Option c is incorrect because contact with the newborn supports bonding and learning and should not be limited.

Correct Answer: Continue to assess and support bonding

Signs of weak attachment call for ongoing assessment and supportive interventions that encourage interaction, rather than judgment, to strengthen the developing bond. Option a is incorrect because these behaviors are warning signs of impaired bonding, not normal responses to ignore. Option b is incorrect because telling the parent they are failing is shaming and undermines the bonding the nurse is trying to build. Option d is incorrect because the nurse supports bonding rather than removing the newborn based on early observations.

Correct Answer: Cleanse from front to back

Cleansing and wiping from front to back prevents bacteria from the rectal area from reaching the perineum and urethra, lowering the risk of infection. Option a is incorrect because firm scrubbing can irritate healing tissue, so gentle cleansing is recommended. Option b is incorrect because wiping back to front carries bacteria toward the urethra and raises the infection risk. Option c is incorrect because tampons are avoided in the postpartum period because they increase the risk of infection.

Correct Answer: Apply warm compresses before feeding

For a breastfeeding client, warm compresses before feeding promote milk flow and help empty the breast, which relieves engorgement; cool compresses can be used afterward. Option a is incorrect because skipping feedings allows milk to build up and worsens engorgement. Option c is incorrect because ice before feeding can slow milk flow, making it harder to relieve the engorgement. Option d is incorrect because tight binding is used to suppress milk in clients who are not breastfeeding, not to relieve engorgement in those who are.

Correct Answer: Wear a supportive bra continuously

A client who is not breastfeeding wears a supportive bra and avoids stimulation so milk production decreases; cold compresses and avoiding warmth also help suppress it. Option b is incorrect because expressing milk signals the body to make more, which prolongs engorgement. Option c is incorrect because warmth stimulates milk flow, which is undesirable when suppressing lactation. Option d is incorrect because massage stimulates the breasts and encourages milk production rather than suppressing it.

Correct Answer: Avoid lifting anything heavier than the newborn

After a cesarean birth, the client avoids lifting anything heavier than the newborn for the first weeks to protect the incision and support healing. Option a is incorrect because stair climbing is limited at first rather than encouraged frequently. Option c is incorrect because heavy lifting strains the incision and is avoided during early recovery. Option d is incorrect because abdominal exercises are postponed for several weeks after a cesarean birth.

Correct Answer: I cannot get pregnant while breastfeeding

Pregnancy can occur during breastfeeding even before menses return, so believing breastfeeding prevents pregnancy shows the client needs further teaching. Option b is incorrect because avoiding estrogen pills until milk is well established is correct teaching for a breastfeeding client. Option c is incorrect because recognizing that pregnancy can occur before the period returns is accurate, not a misconception. Option d is incorrect because planning to discuss options with the provider reflects appropriate understanding.