Halbert Test 5 ATI Questions

A nurse is performing a fundal assessment for a client who is 2 days postpartum & observes the perineal pad for lochia that is bright red & contains small clots. Which of the following findings should the nurse document?

• Moderate lochia rubra

• Excessive lochia serosa

• Light lochia rubra

• Scant lochia serosa

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

• Evidence of a possible vaginal hematoma

• An indication of a cervical or perineal laceration

• A normal postural discharge of lochia

• Abnormally excessive lochia rubra flow

A nurse is completing postpartum discharge teaching to a client who had no immunity to varicella & was given the varicella vaccine. Which of the following statements by the client indicates understanding of the teaching?

• "I will need to use contraception for 3 months before considering pregnancy."

• "I need a second vaccination at my postpartum visit."

• "I was given the vaccine because my baby is O-positive."

• "I will be tested in 3 months to see if I have developed immunity."

A nurse is assessing a postpartum client for fundal height, location, and consistency. The fundus is noted to be displaced laterally to the right, and there is uterine atony. The nurse should identify which of the following conditions as the cause of the uterine atony?

• Poor involution

• Urinary retention

• Hemorrhage

• Infection

A nurse is providing education to a client who is 2hr postpartum & has perineal laceration. Which of the following information should the nurse include? (SATA)

• Use a perineal squeeze bottle to cleanse the perineum

• Sit on the perineum while resting in bed

• Apply a topical anesthetic cream or spray to the perineum

• Wipe the perineum thoroughly with a back-and-forth motion

• Apply cold or ice packs to the perineum

A nurse concludes that the parent of a newborn is not showing positive indications of parent-infant bonding. The parent appears very anxious & nervous when asked to bring the newborn to the other parent. Which of the following actions should the nurse use to promote parent-infant bonding?

• Hand the parent the newborn, and suggest that they change the diaper

• Ask the parent why they are so anxious and nervous

• Tell the parent that they will grow accustomed to the newborn

• Provide education about infant care when the parent is present

A client in the early postpartum period is very excited and talkative. They repeatedly tell the nurse every detail of the labor & birth. Because the client will not stop talking, the nurse is having difficulty completing the postpartum assessments. Which of the following action should the nurse take?

• Come back later when the client is more cooperative

• Give the client time to express feelings

• Tell the client they need to be quiet so the assessment can be completed

• Redirect the client's focus so that they will become quiet

A nurse is caring for a client who is 1 day postpartum. The nurse is assessing for maternal adaptation & parent-infant bonding. Which of the following behaviors by the client indicates a need for the nurse to intervene? (SATA)

• Demonstrates apathy when the newborn cries

• Touches the newborn & maintains close physical proximity

• Views the newborn's behavior as uncooperative during diaper change

• Identifies & relates newborn's characteristics to those of family members

• Interprets the newborn's behavior as meaningful & a way of expressing needs

A nurse is caring for a client who is 2 days postpartum. The client states, "My 4-year-old son was toilet trained & now he is frequently wetting himself." Which of the following statements should the nurse provide to the client?

• "Your son was probably not ready for toilet training & should wear training pants."

• "Your son is showing an adverse sibling response."

• "Your son may need counseling."

• "You should try sending your son to preschool to resolve this behavior."

A nurse in the delivery room is planning to promote parent-infant bonding for a client who just delivered. Which of the following is the priority action by the nurse?

• Encourage the parents to touch & explore the neonate's features

• Limit noise & interruption in the delivery room

• Place the neonate at the client's breast

• Position the neonate skin-to-skin on the client's chest