ATI LPN
PN ATI Capstone Maternal Newborn
1. A client who has undergone a cesarean birth is receiving discharge instructions from a nurse. Which of the following should the nurse include in the instructions?
- A. Limit stair climbing for the first few weeks
- B. Avoid lifting anything heavier than the newborn
- C. Use a pillow to support the abdomen when coughing or sneezing
- D. All of the above
Correct answer: D
Rationale: After a cesarean birth, it is important for the client to follow specific instructions for optimal recovery. Limiting stair climbing reduces strain on the incision site, aiding in healing (Choice A). Avoiding lifting anything heavier than the newborn prevents stress on the incision, promoting recovery (Choice B). Using a pillow to support the abdomen during coughing or sneezing helps reduce discomfort and protect the incision, preventing sudden movements or strain (Choice C). Therefore, all the options provided are crucial post-cesarean birth instructions to ensure proper healing and recovery. Choices A, B, and C are all essential components of post-cesarean care, making Option D the correct answer.
2. 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.
3. A healthcare professional is preparing to administer ceftriaxone. Which of the following actions should the healthcare professional take?
- A. Reconstitute the medication with normal saline
- B. Reconstitute the medication with sterile water
- C. Administer the medication over 30 minutes
- D. Monitor for signs of toxicity
Correct answer: B
Rationale: Correct Answer: B. Ceftriaxone should be reconstituted with sterile water, not saline. Reconstituting it with normal saline can result in a chemical interaction and precipitation of the drug. Administering the medication over 30 minutes (choice C) is not necessary as ceftriaxone is usually given as an intravenous bolus or drip over a shorter period. Monitoring for signs of toxicity (choice D) is important but not the immediate action required for preparing the medication. The priority is to ensure proper reconstitution with the appropriate solvent, which is sterile water.
4. A nurse is caring for a client who is postoperative following a thyroidectomy. The client reports tingling in the fingers and around the mouth. The nurse should anticipate which of the following interventions?
- A. Administer calcium gluconate
- B. Provide a high-protein diet
- C. Administer levothyroxine
- D. Apply a warm compress to the client's neck
Correct answer: A
Rationale: Tingling in the fingers and around the mouth is a sign of hypocalcemia, which can occur after thyroid surgery due to accidental damage to the parathyroid glands. Hypocalcemia is common after thyroidectomy due to potential parathyroid damage. Calcium gluconate is the appropriate intervention to treat hypocalcemia. Providing a high-protein diet or administering levothyroxine are not indicated for hypocalcemia. Applying a warm compress to the client's neck would not address the underlying issue of hypocalcemia.
5. When teaching a client about the use of trazodone, what should be included?
- A. It can cause sedation
- B. It is a stimulant
- C. It has no side effects
- D. It should be taken with food
Correct answer: A
Rationale: The correct answer is A. Trazodone can cause sedation, so clients should be cautioned about activities requiring alertness, like driving. Choice B is incorrect because trazodone is not a stimulant; it is actually a sedating antidepressant. Choice C is incorrect as all medications have potential side effects. Choice D is not specifically indicated for trazodone; the client should follow the prescribing healthcare provider's instructions regarding food intake.
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