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?
- A. WBC count 11,000/mm³
- B. Hgb 11.2 g/dL
- C. Hct 34%
- D. Platelets 140,000/mm³
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 nurse is caring for a client in active labor. The nurse notes variable decelerations in the fetal heart rate. Which of the following is the priority nursing action?
- A. Administer oxygen
- B. Reposition the client
- C. Prepare for delivery
- D. Increase IV fluids
Correct answer: B
Rationale: The correct answer is to reposition the client. Variable decelerations are often caused by umbilical cord compression. Repositioning the client can help alleviate pressure on the cord and improve fetal oxygenation. Administering oxygen may be necessary in some situations, but repositioning the client takes precedence to address the underlying cause of variable decelerations. While preparing for delivery is important, addressing the immediate concern of variable decelerations by repositioning the client is the priority. Increasing IV fluids is not the priority in this situation as it does not directly address the cause of variable decelerations.
3. A client with a new diagnosis of heart failure is prescribed furosemide. Which of the following instructions should the nurse include?
- A. Take the medication in the morning.
- B. Increase intake of potassium-rich foods.
- C. Report a decrease in urine output.
- D. Expect swelling in the lower extremities.
Correct answer: B
Rationale: The correct answer is to instruct the client to increase their intake of potassium-rich foods. Furosemide, a loop diuretic, can lead to potassium loss, which may cause hypokalemia. Increasing potassium intake can help prevent this electrolyte imbalance. Choice A is incorrect because furosemide is usually taken in the morning to prevent sleep disturbances due to increased urination. Choice C is incorrect because a decrease in urine output could indicate a problem and should be reported immediately. Choice D is incorrect because furosemide is used to reduce swelling in the body, including the lower extremities, so expecting swelling is not appropriate.
4. A patient is receiving chemotherapy and reports nausea. Which of the following dietary recommendations should the nurse make?
- A. Eat foods served hot
- B. Drink liquids between meals
- C. Eat dry cereal
- D. Choose foods with a strong aroma
Correct answer: C
Rationale: The correct recommendation for a patient receiving chemotherapy and experiencing nausea is to suggest eating dry, bland foods like cereal. These types of foods are often better tolerated as they are less likely to trigger nausea compared to aromatic or hot foods. Drinking liquids between meals, as suggested in option B, can be helpful to prevent dehydration but may not specifically address the nausea. Eating foods with a strong aroma, as in option D, may actually worsen nausea in patients undergoing chemotherapy.
5. A nurse is caring for a client who has a new diagnosis of tuberculosis (TB). The client has a productive cough and is started on airborne precautions. Which of the following interventions should the nurse implement?
- A. Wear an N95 respirator mask when caring for the client.
- B. Place the client in a semi-private room.
- C. Have the client wear a surgical mask during meals.
- D. Use a negative pressure air filtration system.
Correct answer: A
Rationale: The correct answer is to wear an N95 respirator mask when caring for the client with TB. This is crucial to prevent the nurse from inhaling the airborne particles that spread the infection. Choice B is incorrect because placing the client in a semi-private room does not address the protection of the nurse. Choice C is incorrect as having the client wear a surgical mask during meals is not sufficient to protect the nurse during all interactions. Choice D is incorrect as using a negative pressure air filtration system is more applicable to airborne infection isolation rooms in healthcare settings and not a standard intervention for nurses caring for a single client with TB.
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