ATI LPN
PN ATI Capstone Maternal Newborn
1. A nurse is assessing a newborn whose mother had gestational diabetes. Which of the following findings should the nurse identify as a manifestation of hypoglycemia?
- A. Hypertonia
- B. Jitteriness
- C. Acrocyanosis
- D. Generalized petechiae
Correct answer: B
Rationale: Jitteriness is a common sign of hypoglycemia in newborns. Other signs may include irritability, poor feeding, and lethargy. Choice A, Hypertonia, is not typically associated with hypoglycemia but rather with conditions like hypocalcemia. Acrocyanosis (Choice C) is a benign condition characterized by peripheral cyanosis and is not directly linked to hypoglycemia. Generalized petechiae (Choice D) are tiny red or purple spots on the skin due to bleeding and are not specific to hypoglycemia.
2. A healthcare provider is preparing to administer an influenza vaccine to an adult client. Which of the following is a contraindication?
- A. Client has a low-grade fever
- B. Client is allergic to eggs
- C. Client had recent surgery
- D. Client is on corticosteroid therapy
Correct answer: B
Rationale: The correct answer is B: Client is allergic to eggs. The influenza vaccine is contraindicated in individuals with an allergy to eggs because some influenza vaccines are produced using egg-based processes. Choices A, C, and D are not contraindications for administering the influenza vaccine. A low-grade fever, recent surgery, and corticosteroid therapy are not contraindications for receiving the influenza vaccine.
3. A nurse is caring for a client who has mild anxiety. Which of the following findings should the nurse expect?
- A. Feelings of dread
- B. Rapid speech
- C. Purposeless activity
- D. Heightened perceptual field
Correct answer: D
Rationale: In mild anxiety, the client is expected to have a heightened perceptual field. This means that their perception is increased, enhancing their awareness and ability to concentrate. Feelings of dread (Choice A) are more common in moderate to severe anxiety. Rapid speech (Choice B) and purposeless activity (Choice C) are more indicative of moderate to severe anxiety where the individual may exhibit signs of agitation and restlessness.
4. What can cause a low pulse oximetry reading?
- A. Hyperthermia
- B. Increased hemoglobin level
- C. Inadequate peripheral circulation
- D. Low altitudes
Correct answer: C
Rationale: Inadequate peripheral circulation can cause a low pulse oximetry reading by limiting blood flow to the area being measured, leading to inaccurate oxygen saturation readings. Hyperthermia (choice A) is an elevated body temperature and does not directly affect pulse oximetry readings. An increased hemoglobin level (choice B) would actually lead to higher oxygen-carrying capacity in the blood, resulting in normal or increased pulse oximetry readings. Low altitudes (choice D) typically do not cause low pulse oximetry readings unless there are other underlying conditions affecting oxygen levels.
5. A client newly diagnosed with asthma is receiving discharge instructions from a nurse. Which statement by the client indicates an understanding of the teaching?
- A. I will use my fluticasone inhaler to treat asthma attacks.
- B. I will use a peak flow meter once a week.
- C. I will keep a diary of when I use my albuterol inhaler.
- D. I will limit my fluid intake to prevent mucus production.
Correct answer: C
Rationale: The correct answer is C. Keeping a diary of albuterol use helps monitor the frequency and severity of asthma symptoms, which can guide the healthcare provider in adjusting treatment as needed. Option A is incorrect because fluticasone is a controller medication used for long-term management, not for treating acute asthma attacks. Option B is incorrect as using a peak flow meter once a week may not provide real-time information on asthma control. Option D is incorrect as limiting fluid intake does not directly prevent mucus production in asthma.
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