ATI LPN
PN ATI Capstone Maternal Newborn
1. A client is in active labor and is receiving an epidural for pain relief. Which of the following should the nurse monitor as the priority?
- A. Fetal heart rate
- B. Client's blood pressure
- C. Client's respiratory rate
- D. Client's pain level
Correct answer: B
Rationale: The most common side effect of an epidural is hypotension, which can compromise placental perfusion. Monitoring the client's blood pressure is the priority to ensure maternal and fetal well-being. Fetal heart rate is important but monitoring the client's blood pressure takes precedence due to the risk of hypotension. Respiratory rate and pain level monitoring are also important but not the priority in this scenario.
2. A nurse in an emergency department is serving on a committee that is reviewing the facility protocol for disaster readiness. The nurse should recommend that the protocol include which of the following as a clinical manifestation of smallpox?
- A. Bloody diarrhea
- B. Ptosis of the eyelids
- C. Descending paralysis
- D. Rash in the mouth
Correct answer: D
Rationale: The correct answer is D, 'Rash in the mouth.' Smallpox presents with a distinctive rash that typically begins in the mouth and spreads to the rest of the body, developing into pustules. This rash is a key clinical manifestation of smallpox. This infectious disease is characterized by the rash, fever, and other systemic symptoms. Choices A, B, and C are incorrect because they are not associated with smallpox. Bloody diarrhea, ptosis of the eyelids, and descending paralysis are not typical clinical manifestations of smallpox.
3. A nurse is obtaining the medical history of a client who has a new prescription for isosorbide mononitrate. Which of the following should the nurse identify as a contraindication to this medication?
- A. Glaucoma
- B. Hypertension
- C. Polycythemia
- D. Migraine headaches
Correct answer: A
Rationale: Isosorbide mononitrate is contraindicated in clients with glaucoma due to its potential to increase intraocular pressure, which can exacerbate the condition. Hypertension, polycythemia, and migraine headaches are not contraindications for isosorbide mononitrate. In fact, isosorbide mononitrate is commonly used in the management of hypertension and certain types of angina.
4. A healthcare provider is educating a patient on the use of alendronate. Which of the following should be included?
- A. Take it with food
- B. Take it once a week
- C. It can be taken at bedtime
- D. Monitor for increased appetite
Correct answer: B
Rationale: The correct answer is B: 'Take it once a week.' Alendronate is typically taken once a week to treat osteoporosis. It should be taken on an empty stomach in the morning with a full glass of water. Choice A is incorrect because alendronate should be taken on an empty stomach, not with food. Choice C is incorrect because alendronate should be taken in the morning, not at bedtime. Choice D is unrelated to alendronate use and not a common side effect associated with this medication.
5. A nurse is completing an assessment of a newborn who is 2 hours old. Which of the following findings is indicative of cold stress?
- A. Respiratory rate of 60 per minute
- B. Jitteriness of the hands
- C. Diaphoresis
- D. Bounding peripheral pulses
Correct answer: B
Rationale: Jitteriness of the hands is a classic sign of cold stress in newborns, indicating that the infant is having difficulty maintaining a stable body temperature. Cold stress can lead to hypoglycemia and increased oxygen consumption. The other options (A, C, and D) are not directly associated with cold stress in newborns. A respiratory rate of 60 per minute may be within the normal range for a newborn. Diaphoresis (excessive sweating) and bounding peripheral pulses are not specific signs of cold stress in newborns.
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