ATI LPN
PN ATI Capstone Maternal Newborn
1. A nurse is caring for a newborn who has respiratory distress. Which of the following actions should the nurse take first?
- A. Administer oxygen via nasal cannula
- B. Place the newborn in a prone position
- C. Suction the newborn's airway
- D. Notify the healthcare provider
Correct answer: C
Rationale: In cases of respiratory distress, the nurse should first suction the newborn's airway to clear any obstructions. This is a priority intervention as it helps ensure the airway is patent and allows for effective breathing. Administering oxygen, placing the newborn in a prone position, and notifying the healthcare provider are all important actions but should come after ensuring the airway is clear. Administering oxygen may not be effective if the airway is obstructed. Placing the newborn in a prone position can worsen respiratory distress in infants. While notifying the healthcare provider is important, immediate intervention to clear the airway takes precedence in this situation.
2. A 65-year-old client is taking methylprednisolone. What pharmacological action should the nurse expect with this therapy?
- A. Suppression of beta2 receptors.
- B. Suppression of airway mucus production.
- C. Fortification of bones.
- D. Suppression of candidiasis.
Correct answer: B
Rationale: The correct answer is B: 'Suppression of airway mucus production.' Methylprednisolone, a corticosteroid, is known to suppress airway mucus production. While corticosteroids can enhance the responsiveness of beta2 receptors, they are not directly involved in the suppression of these receptors (Choice A). Corticosteroids can lead to adverse effects such as bone loss, rather than fortification of bones (Choice C). They can also increase the risk of infections like candidiasis but do not directly suppress it (Choice D). Therefore, the most expected pharmacological action of methylprednisolone therapy is the suppression of airway mucus production.
3. A nurse is reviewing the laboratory results of a newborn who is 24 hours old. Which of the following findings should the nurse report to the provider?
- A. Hemoglobin 12 g/dL
- B. Glucose 50 mg/dL
- C. Bilirubin 4 mg/dL
- D. Platelets 200,000/mm³
Correct answer: C
Rationale: The correct answer is C: Bilirubin 4 mg/dL. A bilirubin level of 4 mg/dL is elevated for a newborn and requires monitoring and potential intervention to prevent complications such as jaundice and kernicterus. Elevated bilirubin levels in newborns can lead to serious neurological consequences. Choices A, B, and D are within normal ranges for a newborn and do not require immediate reporting to the provider. Therefore, the nurse should prioritize reporting the elevated bilirubin level to the provider for further evaluation and management.
4. A client receiving oxytocin IV for labor augmentation is experiencing contractions every 45 seconds. What action should the nurse take?
- A. Discontinue the oxytocin infusion
- B. Increase the oxytocin infusion
- C. Decrease the oxytocin infusion
- D. Maintain the oxytocin infusion
Correct answer: A
Rationale: The correct action for the nurse to take in this situation is to discontinue the oxytocin infusion. Contractions occurring every 45 seconds indicate uterine hyperstimulation, which can pose risks to both the client and the fetus. By stopping the oxytocin infusion, the nurse can help prevent further complications. Choices B, C, and D are incorrect because increasing, decreasing, or maintaining the oxytocin infusion can exacerbate the uterine hyperstimulation and increase the risks associated with it.
5. A nurse is caring for a client with deep vein thrombosis (DVT). Which action should the nurse take?
- A. Position the client with the affected extremity lower than the heart
- B. Administer acetaminophen for pain
- C. Massage the affected extremity every 4 hours
- D. Withhold heparin IV infusion
Correct answer: D
Rationale: Withholding heparin IV infusion is the priority if there is a risk of complications such as bleeding, which must be evaluated before continuing treatment.
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