ATI RN
ATI RN Capstone Proctored Comprehensive Assessment A Questions
Extract:
Question 1 of 5
A nurse is assessing a client who is at 37 weeks of gestation and reports sudden, severe abdominal pain with moderate vaginal bleeding and persistent uterine contractions. The client's blood pressure is 88/50 mm Hg and her abdomen is rigid. The nurse should identify these findings as indicating which of the following complications?
Correct Answer: A
Rationale: The correct answer is A: Placental abruption. Placental abruption is characterized by sudden, severe abdominal pain, vaginal bleeding, uterine contractions, low blood pressure, and a rigid abdomen. The abrupt separation of the placenta from the uterine wall can lead to severe maternal and fetal complications. The other choices are incorrect because: B. Amniotic fluid embolus presents with sudden respiratory distress and cardiovascular collapse; C. Placenta previa typically presents with painless vaginal bleeding; D. Uterine rupture may present with sudden abdominal pain but is usually associated with a previous cesarean birth or trauma.
Question 2 of 5
A nurse is assessing a 24-month-old toddler at a well-child checkup. Which of the following findings indicates to the nurse that the toddler has a developmental delay?
Correct Answer: D
Rationale: The correct answer is D. Referring to oneself by name at 24 months is a developmental milestone indicating self-awareness and language development. It shows understanding of personal identity.
Choices A, B, and C are typical gross motor skills for a 24-month-old. Falling when throwing a ball overhand is expected as motor skills are still developing. Going up stairs with two feet on each step is a common way toddlers climb stairs for safety. Running with a wide stance is normal at this age for balance and stability.
Question 3 of 5
A nurse is planning to administer packed RBCs to an older adult client who has a low hemoglobin level. Which of the following actions should the nurse plan to take?
Correct Answer: A
Rationale: The correct answer is A: Infuse the transfusion over 5 hr. This is the correct action because older adults are more susceptible to adverse reactions during blood transfusions. Slow infusion over 5 hours reduces the risk of circulatory overload and other complications.
Choice B is incorrect because dextrose solution is not recommended for blood transfusions.
Choice C is incorrect as a larger gauge IV catheter, typically 18 or 19 gauge, is recommended for transfusing blood products.
Choice D is incorrect as vital signs should be monitored every 15 minutes for the first hour and then every 30 minutes for the remainder of the transfusion, not hourly.
Question 4 of 5
A nurse is teaching about how to suppress lactation with a client who is postpartum and bottle feeding her newborn. Which of the following instructions should the nurse include in the teaching?
Correct Answer: A
Rationale:
Correct Answer: A: You should wear a snug-fitting bra continuously for 72 hours.
Rationale: Wearing a snug-fitting bra provides support and pressure on the breasts, which helps to suppress lactation. This continuous pressure helps to decrease milk production by limiting the milk ducts' ability to refill. By wearing the bra for 72 hours, the client can effectively suppress lactation.
Summary of other choices:
B: Applying moist heat to the breasts can actually stimulate milk production rather than suppress it.
C: Limiting fluid intake to 1 liter per day is not recommended as it can lead to dehydration and does not directly impact lactation suppression.
D: Manually expressing milk when engorgement occurs can stimulate further milk production, which goes against the goal of lactation suppression.
Question 5 of 5
A nurse is performing a physical assessment of a newborn whose mother used cocaine throughout the pregnancy. Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Irritability. Cocaine exposure in utero can lead to central nervous system stimulation in newborns, causing irritability. This is due to the drug's impact on neurotransmitters. Increased head circumference and decreased auditory startle response are not typically associated with cocaine exposure. Hypotonicity is more commonly seen in infants exposed to substances like opioids. The key here is to recognize the stimulant effects of cocaine on the central nervous system.