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 nurse is providing discharge instructions to a client after a myocardial infarction. Which of the following should be included?
- A. Resume normal activities immediately
- B. Monitor for chest pain and report any recurrence
- C. Avoid all physical activity for 6 months
- D. Take medications only as needed
Correct answer: B
Rationale: The correct answer is B: 'Monitor for chest pain and report any recurrence.' After a myocardial infarction, it is crucial for clients to be vigilant about any signs of chest pain as it could indicate a recurrent event. Prompt reporting of chest pain can lead to timely intervention, preventing further complications. Choice A is incorrect because resuming normal activities immediately after a heart attack can be dangerous and is not recommended. Choice C is also incorrect as avoiding all physical activity for 6 months is excessive and can lead to deconditioning. Choice D is incorrect as medications prescribed after a myocardial infarction are usually meant to be taken regularly as prescribed, not just as needed.
3. A nurse is assessing a client who has a femur fracture and is in skeletal traction. Which of the following findings should the nurse report to the provider?
- A. Clear fluid drainage from the pin sites
- B. Client reporting intermittent muscle spasms
- C. Client reporting severe pain despite receiving analgesics
- D. The traction weights are hanging freely
Correct answer: C
Rationale: The correct answer is C. Severe pain that is not relieved by analgesics may indicate neurovascular compromise or other complications and requires immediate attention by the provider. Choices A, B, and D are incorrect because clear fluid drainage from the pin sites is expected in skeletal traction, intermittent muscle spasms are common in this situation, and traction weights hanging freely indicate proper traction alignment.
4. A nurse is caring for a client with a new prescription for atorvastatin. Which of the following should the nurse monitor?
- A. Liver function tests
- B. Potassium levels
- C. Blood glucose levels
- D. Serum calcium levels
Correct answer: A
Rationale: The correct answer is A: Liver function tests. Atorvastatin, a medication commonly used to lower cholesterol levels, can potentially cause liver damage as a side effect. Monitoring liver function tests is essential to detect any abnormalities early. Choices B, C, and D are incorrect because atorvastatin is not known to directly impact potassium levels, blood glucose levels, or serum calcium levels. While these parameters may be monitored for other reasons, the priority when administering atorvastatin is to monitor liver function due to the risk of hepatotoxicity.
5. A nurse is caring for a client with hepatic encephalopathy. Which food selection indicates an understanding of dietary teaching?
- A. Cottage cheese
- B. Tuna salad
- C. Rice with black beans
- D. Three-egg omelet
Correct answer: C
Rationale: The correct answer is C: 'Rice with black beans.' Clients with hepatic encephalopathy should limit animal proteins due to their high ammonia content, which can exacerbate symptoms. Plant-based proteins like beans are preferred as they help reduce ammonia levels. Choices A, B, and D contain animal proteins that are not ideal for clients with hepatic encephalopathy.
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