ATI LPN
PN ATI Capstone Maternal Newborn
1. A nurse is providing discharge instructions to parents of a circumcised newborn. To prevent diaper adherence to the penis, what will be recommended to apply during diaper changes?
- A. Baby oil
- B. Antibiotic ointment
- C. Petroleum jelly
- D. Alcohol wipes
Correct answer: C
Rationale: Petroleum jelly is recommended to prevent the diaper from sticking to the circumcised area, reducing irritation and promoting healing. It should be applied during every diaper change until the site heals. Baby oil (Choice A) is not recommended as it may not provide a sufficient barrier to prevent adherence. Antibiotic ointment (Choice B) is not typically used for this purpose and can sometimes cause irritation. Alcohol wipes (Choice D) are too harsh for the sensitive skin of a newborn and can cause irritation.
2. A nurse is assessing a client 2 hours after a vaginal delivery and notes that the client's uterus is boggy and displaced to the right. Which of the following interventions should the nurse perform first?
- A. Assist the client to void
- B. Massage the uterus
- C. Administer oxytocin
- D. Encourage breastfeeding
Correct answer: A
Rationale: A boggy and displaced uterus is often a sign of bladder distention, which can prevent the uterus from contracting effectively. The priority intervention is to assist the client to void. By emptying the bladder, the uterus can return to midline and become firm. Massaging the uterus or administering oxytocin may be necessary but should come after addressing the bladder distention. Encouraging breastfeeding is important for uterine contraction but is not the priority in this situation.
3. A healthcare professional is assessing a client for signs of hypoglycemia. Which of the following findings should the healthcare professional look for?
- A. Increased thirst
- B. Fatigue
- C. Weight gain
- D. Elevated blood pressure
Correct answer: B
Rationale: The correct answer is B: Fatigue. Fatigue, along with symptoms like shakiness and irritability, are common signs of hypoglycemia. Increased thirst (Choice A) is more indicative of hyperglycemia. Weight gain (Choice C) is not typically associated with hypoglycemia. Elevated blood pressure (Choice D) is not a common sign of hypoglycemia.
4. A nurse is preparing to administer a dose of insulin. Which of the following should the nurse do first?
- A. Check the expiration date
- B. Verify the client's blood glucose level
- C. Obtain the client's weight
- D. Assess for signs of hypoglycemia
Correct answer: B
Rationale: The correct answer is to verify the client's blood glucose level first before administering insulin. This step is crucial to determine the appropriate dose of insulin based on the client's current blood glucose level. Checking the expiration date (Choice A) is important but not the first step in this scenario. Obtaining the client's weight (Choice C) is not directly related to the immediate administration of insulin. Assessing for signs of hypoglycemia (Choice D) should be done after administering insulin to monitor for potential side effects or adverse reactions.
5. A nurse is assessing a client for signs of anemia. Which of the following findings should the nurse look for?
- A. Increased energy
- B. Pale skin
- C. Elevated blood pressure
- D. Weight gain
Correct answer: B
Rationale: The correct answer is B: 'Pale skin.' Pale skin is a common sign of anemia due to reduced hemoglobin levels, which affects the skin color. Anemia is characterized by a decrease in the number of red blood cells or hemoglobin in the blood, leading to a paler complexion. Choices A, C, and D are incorrect. 'Increased energy' is not typically associated with anemia, as fatigue is a common symptom. 'Elevated blood pressure' is not a typical finding in anemia; instead, anemia may cause hypotension. 'Weight gain' is not a direct symptom of anemia; in fact, weight loss may occur in some cases due to reduced appetite or other factors associated with anemia.
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