a nurse is providing discharge teaching to a client who is postpartum for which of the following clinical manifestations should the nurse instruct the
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Nursing Elites

ATI LPN

Maternal Newborn ATI Proctored Exam 2023

1. A client who is postpartum is receiving discharge teaching from a nurse. For which of the following clinical manifestations should the client be instructed to monitor and report to the provider?

Correct answer: C

Rationale: Unilateral breast pain can be a sign of mastitis, an infection of the breast tissue, which requires prompt evaluation and treatment. The nurse should instruct the client to report this clinical manifestation to the provider to prevent complications and promote recovery.

2. A client at 8 weeks of gestation with iron deficiency anemia is prescribed iron supplements. Which beverage should the nurse reinforce the client to take the supplements with for better absorption?

Correct answer: D

Rationale: The correct answer is 'Orange juice.' Orange juice is recommended to be taken with iron supplements because vitamin C present in orange juice enhances iron absorption, improving the effectiveness of the supplement. It is essential to take iron supplements with a source of vitamin C to optimize iron absorption and address iron deficiency anemia. Ice water (Choice A), low-fat or whole milk (Choice B), and tea or coffee (Choice C) are not ideal choices to take with iron supplements as they do not contain vitamin C, which is crucial for enhancing iron absorption.

3. 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?

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. Excessive lochia serosa is more characteristic of a later postpartum period, while light and scant lochia serosa are not consistent with the bright red color and small clots observed in this case.

4. A pregnant client is learning about Kegel exercises in the third trimester. Which statement signifies understanding of the teaching?

Correct answer: B

Rationale: Kegel exercises are beneficial during pregnancy to help strengthen pelvic muscles, which is crucial for childbirth. Pelvic muscle stretching during birth is a key aspect of labor, making choice B the correct statement indicating understanding of the teaching. Choices A, C, and D are incorrect because Kegel exercises primarily focus on strengthening pelvic floor muscles to support the uterus, bladder, and bowel, aiding in labor and delivery. They are not directly related to preventing constipation, decreasing backaches, or preventing stretch marks.

5. A client in labor requests epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?

Correct answer: C

Rationale: The correct action is to monitor the client's blood pressure every 5 to 10 minutes following the first dose of anesthetic solution to assess for maternal hypotension. This is crucial to detect and manage potential complications associated with the epidural anesthesia. Positioning the client supine for a prolonged period can lead to hypotension; administering dextrose solution is not a standard practice in epidural anesthesia; ensuring NPO status for 4 hours is not necessary before epidural placement.

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