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ATI Pediatrics Test Bank
1. The nurse is assessing a postpartum client's fundus. Where should the nurse expect to find the fundus 24 hours after delivery?
- A. At the level of the umbilicus
- B. 1 cm above the symphysis pubis
- C. At the level of the xiphoid process
- D. 2 cm below the umbilicus
Correct answer: A
Rationale: After delivery, the fundus is expected to be at the level of the umbilicus 24 hours postpartum. This position indicates that the uterus is involuting properly. Assessing the fundal height helps monitor the progress of uterine involution and can identify any potential complications like postpartum hemorrhage.
2. The healthcare provider is preparing to administer Rh immune globulin (RhoGAM) to a postpartum client. This medication is indicated for:
- A. Rh-negative individuals with Rh-positive infants
- B. Rh-positive individuals with Rh-negative infants
- C. All individuals regardless of Rh status
- D. Individuals with a history of Rh incompatibility
Correct answer: A
Rationale: Rh immune globulin (RhoGAM) is administered to Rh-negative individuals who have given birth to Rh-positive infants to prevent Rh sensitization. When an Rh-negative individual gives birth to an Rh-positive infant, there is a risk of the mother developing antibodies against the Rh-positive blood cells, which can lead to hemolytic disease of the newborn in subsequent pregnancies. Rh immune globulin is given to prevent this sensitization in Rh-negative individuals who deliver Rh-positive infants.
3. A postpartum client is being discharged and asks the nurse when she should expect her menstrual period to return if she is not breastfeeding. The nurse's best response is:
- A. In about 6 to 8 weeks
- B. In about 3 to 4 months
- C. In about 6 months
- D. In about 1 year
Correct answer: A
Rationale: For non-breastfeeding mothers, the return of menstrual periods typically occurs around 6 to 8 weeks postpartum. This timeframe may vary among individuals, but generally, hormonal changes after childbirth lead to the resumption of menstrual cycles within this period.
4. A new parent is concerned because their newborn's stools are loose and yellow. The healthcare provider should explain that this is:
- A. A sign of dehydration
- B. A normal finding in breastfed infants
- C. Indicative of an infection
- D. Due to lactose intolerance
Correct answer: B
Rationale: Loose, yellow stools are a normal finding in breastfed infants. Breastfed infants often have loose, yellow stools due to the composition of breast milk. It is not typically a sign of dehydration, infection, or lactose intolerance in this context.
5. The healthcare provider assesses a postpartum client who is 1 day post-delivery. Which finding would require immediate intervention?
- A. Lochia rubra with a few small clots
- B. Fundus firm and midline
- C. Temperature of 100.4°F (38°C)
- D. Saturated perineal pad in 15 minutes
Correct answer: D
Rationale: A saturated perineal pad in 15 minutes indicates excessive bleeding, which is abnormal postpartum. This finding could suggest hemorrhage, requiring immediate intervention to prevent further complications like hypovolemic shock. Monitoring and managing postpartum bleeding are crucial to ensure the client's safety and prevent serious consequences.
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