a nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation which of the following results should the nurse report to the
Logo

Nursing Elites

ATI LPN

PN ATI Capstone Maternal Newborn

1. A nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation. Which of the following results should the nurse report to the provider?

Correct answer: D

Rationale: A platelet count of 140,000/mm³ is at the lower end of the normal range but can be concerning in pregnancy, especially if there are signs of thrombocytopenia or bleeding. Thrombocytopenia in pregnancy can lead to complications such as bleeding during childbirth or excessive bleeding postpartum. The other laboratory values mentioned are within normal ranges for pregnancy and do not typically raise immediate concerns. High WBC counts can be a normal response to pregnancy, hemoglobin levels around 11.2 g/dL and hematocrit levels around 34% are also considered normal in the third trimester.

2. A client with a new ileostomy is receiving discharge instructions from a nurse. Which statement indicates the client understands the teaching?

Correct answer: B

Rationale: The correct answer is B. Ileostomy stomas typically drain liquid continuously, unlike colostomies. This continuous drainage is a key characteristic that clients should understand postoperatively. Choice A is incorrect because ensuring medications are enteric-coated is not directly related to understanding ileostomy care. Choice C is incorrect as changing the pouch system every two weeks is not a general rule and may vary depending on the individual's needs. Choice D is incorrect because the stoma size can change during the healing process and clients should be informed about this possibility.

3. A nurse is preparing to administer a client's first dose of a new antibiotic. Which of the following is the priority nursing action?

Correct answer: A

Rationale: Assessing allergies before administering a new medication is crucial as it helps prevent potentially life-threatening allergic reactions like anaphylaxis. While monitoring vital signs and informing the client of side effects are important nursing actions, assessing allergies takes precedence to ensure the client's safety. Informed consent is necessary for the treatment process, but assessing allergies is the priority before administering any new medication.

4. During a breast examination on a 24-year-old client, the nurse notes the following findings. Which finding is of most concern and should be reported to the provider?

Correct answer: A

Rationale: An irregularly shaped, nontender lump is a concerning finding as it may indicate breast cancer. The nurse should report this finding to the provider for further investigation. Choices B, C, and D are less concerning findings. Tenderness during menstruation is a common finding due to hormonal changes. Bilateral, symmetrical lumps that move with palpation are often benign findings like fibrocystic changes. Breast tenderness before menstruation is also a common occurrence related to hormonal fluctuations.

5. A client who is 2 hours postpartum reports heavy bleeding and passing large clots. What is the nurse's priority action?

Correct answer: A

Rationale: The correct answer is A: Perform fundal massage. Fundal massage promotes uterine contractions, which is the initial action to reduce postpartum hemorrhage caused by uterine atony. Checking vital signs (choice C) is important but not the priority when active bleeding is present. Administering oxytocin IV (choice B) may be needed but is not the priority action. Encouraging the client to void (choice D) does not address the underlying issue of postpartum hemorrhage and should not be the priority.

Similar Questions

A nurse is caring for an older adult who has a non-palpable skin lesion that is less than 0.5 cm in diameter. Which term should the nurse use to document this finding?
A nurse is caring for a client who has been taking haloperidol for several years. Which of the following assessment findings should the nurse recognize as a long-term side effect of this medication?
A nurse is providing discharge teaching to a client following a heart transplant. Which of the following information should the nurse include in the teaching?
A nurse is teaching a group of clients about stress management. Which of the following activities should the nurse recommend to reduce stress?
A client is being educated by a nurse on how to use a PCA pump postoperatively. Which statement by the client indicates understanding?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses