ATI RN
ATI Capstone Week 11 Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood work, the nurse notices she does not have immunity to rubella. Which of the following times should the nurse understand is recommended for rubella immunization?
Correct Answer: B
Rationale: The correct answer is B: Shortly after giving birth. Rubella vaccine is contraindicated during pregnancy to avoid any potential harm to the fetus. Postpartum vaccination ensures the client is protected before her next pregnancy. Option A is incorrect as it is contraindicated during the third trimester. Option C is incorrect because immediate vaccination during pregnancy is not recommended. Option D is incorrect as it is essential to vaccinate postpartum, not during the next attempt to get pregnant to prevent rubella infection during pregnancy.
Question 2 of 5
A nurse is monitoring a client who is postoperative following a thyroidectomy. Which of the following data should the nurse identify as the priority to monitor?
Correct Answer: A
Rationale: The correct answer is A: Airway patency. In the postoperative period following a thyroidectomy, airway patency is the priority to monitor due to the risk of airway obstruction from swelling or bleeding. If the airway is compromised, it can lead to serious complications such as respiratory distress or even respiratory arrest. Monitoring airway patency involves assessing for signs of respiratory distress, such as stridor, difficulty breathing, or changes in oxygen saturation. Temperature, pain control, and urination are important to monitor postoperatively, but ensuring the client's airway is clear and functioning properly takes precedence to prevent life-threatening complications.
Question 3 of 5
A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes early decelerations on the monitor strip and interprets them as indicating which of the following?
Correct Answer: C
Rationale: The correct answer is C: Fetal head compression. Early decelerations are gradual, mirror the contraction pattern, and are caused by pressure on the fetal head during contractions. This is a normal response to labor and does not indicate fetal distress. Umbilical cord compression (choice
A) would result in variable decelerations. Uteroplacental insufficiency (choice
B) would cause late decelerations. Maternal bradycardia (choice
D) would not directly affect the fetal heart rate.
Question 4 of 5
A nurse is providing teaching about phenylketonuria (PKU) testing to the parent of a newborn. Which of the following statements by the parent indicates a need for additional teaching?
Correct Answer: A
Rationale: The correct answer is A because PKU testing does not involve placing the baby under special lights. The test is a simple blood test to check for levels of phenylalanine. Placing the baby under special lights is a treatment for jaundice, not for PKU.
Choice B is correct as PKU can be managed with a special diet low in phenylalanine.
Choice C is accurate as sometimes the test is repeated to confirm the results.
Choice D is also correct as the baby needs to be consuming protein (from formula or breast milk) before the test.
Question 5 of 5
A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is 'not really sure if she is in labor colp or not.' Which of the following should the nurse recognize as a sign of true labor?
Correct Answer: C
Rationale: The correct answer is C: Changes in the cervix. In true labor, the cervix undergoes changes such as effacement (thinning) and dilation (opening). These cervical changes are indicative of the onset of labor and progression towards childbirth. By assessing the cervix, the nurse can determine if the client is indeed in true labor.
Rupture of the membranes (choice
A) may or may not occur in labor, and it alone does not confirm true labor. The pattern of contractions (choice
B) is important but not sufficient to differentiate true labor from false labor. The station of the presenting part (choice
D) refers to the position of the baby's head in relation to the pelvis and is not a definitive sign of true labor.