ATI RN
ATI Capstone Class Exam Week 12 Questions
Extract:
Question 1 of 5
A nurse is assessing a newborn who has developmental dysplasia of the hip (DDH). Which of the following findings should the nurse expect?
Correct Answer: D
Rationale: The correct answer is D: Asymmetric thigh folds. In DDH, there is an abnormal formation of the hip joint which can lead to dislocation. Asymmetric thigh folds result from the shortened thigh muscles on the affected side due to the dislocation. This finding is indicative of DDH as it reflects the displacement of the femoral head. The other choices are incorrect because an inwardly turned foot (
A) is associated with clubfoot, absent plantar reflexes (
B) may indicate neurological issues, and a lengthened thigh (
C) is not a typical finding in DDH.
Question 2 of 5
A nurse is completing a home visit to a mother who is 3 days postpartum and breastfeeding her newborn. The mother expresses concern about the amount of weight the newborn has lost since birth. Which of the following is a response the nurse should make?
Correct Answer: A
Rationale: The correct answer is A because insufficient feeding can lead to excessive weight loss in newborns. Frequent and effective breastfeeding helps ensure the baby receives enough milk and nutrients. Option B is incorrect as maternal hormones do not directly affect newborn weight loss. Option C is incorrect as the number of stools is not necessarily indicative of weight loss. Option D is incorrect as newborns should only be fed breastmilk or formula, not water supplements.
Question 3 of 5
A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider?
Correct Answer: A
Rationale: The correct answer is A: Dyspnea. Terbutaline is a beta-adrenergic agonist that can cause pulmonary edema as a serious adverse effect. Dyspnea is a common symptom of pulmonary edema, indicating potential respiratory distress. This adverse effect should be reported promptly to the provider for further evaluation and management to prevent complications.
Incorrect choices:
B: Headaches - Headaches are a common side effect of terbutaline but are not as concerning as respiratory distress.
C: Nervousness - Nervousness is a common side effect of terbutaline and does not typically require immediate reporting unless severe.
D: Tremors - Tremors are a common side effect of terbutaline and are not as concerning as respiratory distress.
Question 4 of 5
A nurse observes 5 minutes after delivery that a newborn has a pink trunk and head, bluish hands and feet, and a heart rate of 130/min. He has flexed extremities and a weak, slow cry. The nurse should document what Apgar score for this infant?
Correct Answer: B
Rationale: The correct Apgar score for this infant is B: 6. The Apgar score assesses a newborn's overall condition at 1 and 5 minutes after birth based on five criteria: Appearance, Pulse, Grimace, Activity, and Respiration. In this case, the baby has a pink trunk and head (2 points), bluish hands and feet (1 point), a heart rate of 130/min (2 points), flexed extremities (2 points), and a weak, slow cry (1 point). Adding these points together, the Apgar score is 2+1+2+2+1=8. Since the Apgar score ranges from 0 to 10, a score of 6 indicates that the infant may need some assistance but is generally in good condition. Other choices are incorrect because they do not add up correctly based on the described criteria.
Question 5 of 5
A nurse is admitting a client who experienced a vaginal birth 2 hours ago. The client is receiving an IV of lactated Ringer’s with 25 units of oxytocin infusing and has large rubra lochia. Vital signs include blood pressure 146/94 mm Hg, pulse 80/min, and respiratory rate 18/min. The nurse reviews the prescriptions from the provider. Which of the following prescriptions requires clarification?
Correct Answer: C
Rationale: The correct answer is C: Methylergonovine 0.2 mg IM now. This prescription requires clarification because methylergonovine is a uterotonic medication that can cause severe vasoconstriction, leading to increased blood pressure. Given the client's elevated blood pressure of 146/94 mm Hg, administering methylergonovine could potentially worsen hypertension and lead to adverse effects such as stroke or myocardial infarction. It is crucial to address the high blood pressure before considering the administration of methylergonovine. The other options are not immediately concerning:
A) Administering oxygen is appropriate for a client with elevated blood pressure;
B) Obtaining laboratory studies is a routine part of postpartum care to assess for coagulation abnormalities;
D) Inserting an indwelling urinary catheter is commonly done postpartum to monitor urinary output.