a nurse is observing bonding to the client her newborn which of the following actions by the client requires the nurse to intervene
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment A

1. A nurse is observing bonding between the client and her newborn. Which of the following actions by the client requires the nurse to intervene?

Correct answer: D

Rationale: The correct answer is D because viewing the newborn’s actions as uncooperative indicates a negative interaction with the newborn and suggests impaired bonding, which requires intervention. Choices A, B, and C are not indicative of impaired bonding. Holding the newborn in an en face position is a positive way to bond with the baby. Asking the father to change the diaper shows involvement of both parents in caring for the newborn, which is beneficial for bonding. Requesting the nurse to take the newborn to the nursery so the mother can rest is a normal request and does not necessarily indicate impaired bonding.

2. A nurse is caring for a client prescribed gabapentin. Which of the following should the nurse monitor?

Correct answer: B

Rationale: The correct answer is B: Renal function. Gabapentin is primarily eliminated by the kidneys, so monitoring renal function is essential to ensure the drug is being cleared effectively from the body. Monitoring liver function tests (choice A) is not a priority for gabapentin as it is not primarily metabolized by the liver. Blood glucose levels (choice C) are not directly impacted by gabapentin. Cardiac rhythm (choice D) monitoring is not typically necessary for clients on gabapentin unless they have pre-existing cardiac conditions that may be exacerbated by the medication.

3. A client who is Rh-negative is being taught about Rh (D) immune globulin by a nurse. Which statement by the client indicates an understanding of the teaching?

Correct answer: D

Rationale: Choice D is the correct answer because it reflects an understanding of Rh immune globulin administration. Rh immune globulin is given after delivery to prevent sensitization in future pregnancies, particularly if the baby is Rh-positive. Choice A is incorrect because Rh-negative partners do not affect the need for Rh immune globulin. Choice B is incorrect as Rh immune globulin is given if the baby is Rh-positive, not Rh-negative. Choice C is incorrect; there is no requirement to avoid immunizations after receiving Rh immune globulin.

4. A nurse is caring for an older adult client with delirium. Which intervention will most effectively reduce the client's risk for falls?

Correct answer: D

Rationale: Hourly rounding by the nurse is the most effective intervention to reduce the risk of falls in older adult clients with delirium. This intervention ensures that the nurse regularly checks on the client, assesses their needs, and assists them with any activities, thereby minimizing the chances of falls. Using a night-light (choice A) may help improve visibility but does not provide continuous assistance and monitoring. Demonstrating how to use the call light (choice B) is important but may not prevent falls directly. Placing the bedside table in close proximity (choice C) is helpful for convenience but does not address the continuous monitoring and assistance needed to prevent falls in this case.

5. A nurse is caring for a client who has a urinary tract infection (UTI) and is prescribed ciprofloxacin. Which of the following client statements indicates a need for further teaching?

Correct answer: A

Rationale: Clients should be instructed to complete the entire course of antibiotics, even if they start feeling better, to prevent antibiotic resistance and recurrence of infection.

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