ATI RN
ATI Capstone Week 11 Exam Questions
Question 1 of 5
A nurse is caring for a client who is scheduled for a maternal serum alpha-fetoprotein test at 15 weeks of gestation. The nurse provides which of the following explanations about this test to the client?
Correct Answer: C
Rationale: The correct answer is C: This test is a screening test for spinal defects in the fetus. The maternal serum alpha-fetoprotein test is used to screen for neural tube defects such as spina bifida in the fetus. The test measures the levels of alpha-fetoprotein in the mother's blood, which can indicate the presence of such defects. At 15 weeks of gestation, this test is typically done as part of routine prenatal screening.
Explanation for other choices:
A: This test does not identify Rh incompatibility; that is typically determined through other blood tests.
B: While the test may indirectly provide information about fetal well-being, its primary purpose is to screen for spinal defects, not general markers of well-being.
D: Fetal lung maturity is typically assessed using tests such as amniocentesis or ultrasound, not the maternal serum alpha-fetoprotein test.
Question 2 of 5
A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal heart rate begins to slow after the start of a contraction, and the lowest rate occurs after the peak of the contraction. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Place the client in the lateral position. This action helps improve maternal perfusion and oxygenation to the fetus by increasing blood flow to the placenta. Placing the client in the lateral position can alleviate compression on the vena cava, which may be causing the fetal heart rate deceleration. Elevating the client's legs (
B) may not directly address the issue of decreased perfusion. Increasing the rate of maintenance IV infusion (
C) may not be necessary if the vena cava compression is the cause. Administering oxygen using a nonrebreather mask (
D) may be indicated if the fetal heart rate deceleration persists, but placing the client in the lateral position should be the initial intervention.
Question 3 of 5
A nurse is providing home safety information for an older adult client who uses a cane. Which of the following statements should the nurse include in the teaching?
Correct Answer: D
Rationale:
Correct
Answer: D - You should advance your weak leg forward to the cane, then move your strong leg.
Rationale: By advancing the weak leg first, the client's center of gravity is more stable, reducing the risk of falls. Moving the strong leg next provides additional support and balance. This sequence ensures proper weight distribution and minimizes the risk of tripping or losing balance.
Summary of Incorrect
Choices:
A: Advancing the cane too far ahead can lead to imbalance and potential falls.
B: Holding the cane in the weak hand may not provide adequate support and stability.
C: The cane's height should align with the wrist crease, not the mid flank, for proper use and support.
Question 4 of 5
A nurse working in a community health center is preparing a flow sheet detailing essential screenings according to age group. At which developmental stage on the chart should the nurse add scoliosis screening?
Correct Answer: B
Rationale:
Rationale: The correct answer is B (Pre-adolescent/adolescent). Scoliosis screening is typically done during adolescence when rapid growth occurs, making it easier to detect and treat early. Screening during toddler/preschooler stage (
C) may miss early signs. Infants (
D) are not typically screened for scoliosis. Older adults (
A) are less likely to develop scoliosis.
Question 5 of 5
A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?
Correct Answer: C
Rationale: Answer C is correct because at 0 station, the lowermost portion of the fetus is at the level of the ischial spines. This indicates that the baby's head has descended to the level of the maternal ischial spines, which is a significant position in the birthing process. This is a key landmark for monitoring progress during labor.
Option A is incorrect because passing through the pelvic outlet is not the same as being at 0 station. Option B is incorrect because the palpability of the posterior fontanel is unrelated to station. Option D is incorrect because the fetal head position is not specified in the station measurement.