ATI LPN

1. During Leopold maneuvers on a client in labor, which technique should be used by the nurse to identify the fetal lie?

• A. Apply palms of both hands to sides of uterus.
• B. Palpate the fundus of the uterus
• C. Grasp lower uterine segment between thumb and fingers
• D. Stand facing client's feet with fingertips outlining cephalic prominence

Correct Answer: B

Rationale: Palpating the fundus of the uterus during Leopold maneuvers is important to identify the fetal lie. This technique helps the nurse determine the position of the baby's back and the location of the fetal heart sounds, which are crucial in assessing the fetal lie.

2. A client who is 2 days postpartum has a saturated perineal pad with bright red lochia containing small clots. What should the nurse document in the client's medical record?

• A. Moderate lochia rubra
• B. Excessive lochia serosa
• C. Light lochia rubra
• D. Scant lochia serosa

Correct Answer: A

Rationale: The correct answer is 'Moderate lochia rubra.' On the second day postpartum, it is normal for lochia to be bright red and contain small clots, indicating moderate lochia rubra. This amount of bleeding is expected as the uterus continues to shed its lining after childbirth. Excessive lochia serosa, light lochia rubra, and scant lochia serosa do not accurately reflect the described scenario.

3. During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. On data collection, a nurse finds the uterus to be firm, midline, and at the level of the umbilicus. Which of the following findings should the nurse interpret this data as being?

• A. Evidence of a possible vaginal hematoma
• B. An indication of a cervical or perineal laceration
• C. A normal postural discharge of lochia
• D. Abnormally excessive lochia rubra flow

Correct Answer: C

Rationale: The nurse should interpret this data as a normal postural discharge of lochia. Lochia is the normal vaginal discharge after childbirth, and the gush of dark red blood upon ambulation is typical due to the pooling of blood in the vagina when lying down, which is then released upon standing. The firm, midline uterus at the level of the umbilicus indicates normal involution of the uterus postpartum. Therefore, this scenario is consistent with the expected postpartum physiological changes rather than complications like hematoma, lacerations, or abnormal excessive bleeding.

4. A client is receiving postpartum discharge teaching after being vaccinated for varicella due to lack of immunity. Which statement by the client indicates understanding?

• A. I will need to use contraception for 3 months before considering pregnancy.
• B. I need a second vaccination at my postpartum visit.
• C. I was given the vaccine because my baby is O-positive.
• D. I will be tested in 3 months to see if I have developed immunity.

Correct Answer: B

Rationale: The correct answer is B because the client needs a second varicella vaccination at the postpartum visit to ensure immunity. Option A is not relevant to varicella vaccination. Option C is incorrect as varicella vaccination is not based on the baby's blood type. Option D is not the appropriate action as a second vaccination is needed rather than waiting to be tested for immunity.

5. A client who is postpartum and has thrombophlebitis requires nursing interventions. Which of the following nursing interventions should the nurse recommend?

• A. Apply cold compresses to the affected extremity
• B. Massage the affected extremity
• C. Allow the client to ambulate
• D. Measure leg circumferences

Correct Answer: D

Rationale: Measuring leg circumferences is crucial in monitoring for changes that may indicate worsening of thrombophlebitis, such as increased swelling or redness. This assessment helps in early detection of complications and timely intervention, reducing the risk of further health problems for the client.