a nurse is caring for a postpartum client with ab negative blood whose newborn is b positive what is the appropriate intervention
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment Form A

1. A postpartum client with AB negative blood whose newborn is B positive requires what intervention?

Correct answer: A

Rationale: The correct intervention is to administer Rh immune globulin within 72 hours of delivery. This is essential to prevent the mother from forming antibodies against Rh-positive blood, which could cause complications in future pregnancies. Choice B is incorrect as the administration should be immediate postpartum. Choice C is incorrect as Rh immune globulin is needed for each Rh-incompatible pregnancy. Choice D is incorrect as only the mother, who is Rh-negative, needs Rh immune globulin.

2. A nurse is assessing a client with suspected myocardial infarction. Which finding supports this diagnosis?

Correct answer: A

Rationale: The correct answer is A. Pain radiating to the left arm is a classic symptom of myocardial infarction, commonly known as a heart attack. This occurs due to the referred pain pathways shared by the heart and the left arm. Choices B, C, and D are incorrect. Pain relieved by rest (choice B) is more indicative of musculoskeletal pain rather than cardiac-related pain. Pain worsening with deep breathing (choice C) is often seen in conditions like pleurisy or pulmonary embolism, not myocardial infarction. Pain relieved by antacids (choice D) suggests gastrointestinal issues like heartburn or acid reflux, not cardiac-related pain.

3. A nurse is caring for a newborn immediately following birth. What should the nurse do first?

Correct answer: D

Rationale: Drying the newborn is the first priority to prevent heat loss, which can occur rapidly in newborns due to their large surface area and lack of body fat. This helps maintain the newborn's body temperature and prevent hypothermia. Instilling erythromycin ophthalmic ointment, placing identification bracelets, and weighing the newborn can be important steps but should come after ensuring the newborn is dried to maintain their body temperature.

4. A healthcare provider is educating a client about the use of montelukast. Which of the following should be included?

Correct answer: B

Rationale: The correct answer is B. Montelukast is a leukotriene receptor antagonist that is typically taken once daily in the evening for asthma management. Choice A is incorrect as montelukast is not used for acute asthma attacks but rather for the prevention of asthma symptoms. Choice C is also incorrect because montelukast can be taken with or without food. Choice D is misleading as all medications, including montelukast, have potential side effects.

5. A nurse is preparing to administer 2.5 mL of medication intramuscularly to an adult client. Which site is safest for the nurse to use?

Correct answer: A

Rationale: The correct answer is 'Ventrogluteal.' The ventrogluteal site is recommended for intramuscular injections in adults because it is free of major blood vessels and nerves, reducing the risk of injury or complications. Choice B, 'Dorsogluteal,' is not recommended due to the proximity of the sciatic nerve and major blood vessels. Choices C and D, 'Vastus lateralis' and 'Rectus femoris,' are sites commonly used for intramuscular injections but are more suitable for pediatric or specific population groups, not typically for adults.

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