ATI LPN Maternity Exam
ATI LPN Maternity Exam ( 79 Questions)
A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft, fundus firm, slightly deviated to the right moderate lochia rubra; temperature 37.7° C (100° F), pulse rate 88./min, respiratory rate 18/min. Which of the following actions should the nurse perform?
rationale:
Encouraging the client to nurse more frequently will help with milk production and breastfeeding but is not the priority action based on the data provided.
rationale:
A temperature elevation above 38°C (100.4°F) in the postpartum period can indicate infection. The nurse should report this finding to the healthcare provider for further evaluation and management.
rationale:
Increasing IV fluids is not indicated based on the data provided. The client's vital signs are within the expected range for the postpartum period.
rationale:
Emptying the bladder can be important to prevent bladder distention and discomfort, but it is not the priority action based on the data provided.
Choice A rationale:
Encouraging the client to nurse more frequently will help with milk production and breastfeeding but is not the priority action based on the data provided.
Choice B rationale:
A temperature elevation above 38°C (100.4°F) in the postpartum period can indicate infection. The nurse should report this finding to the healthcare provider for further evaluation and management.
Choice C rationale:
Increasing IV fluids is not indicated based on the data provided. The client's vital signs are within the expected range for the postpartum period.
Choice D rationale:
Emptying the bladder can be important to prevent bladder distention and discomfort, but it is not the priority action based on the data provided.