ATI RN
ATI Capstone Class Exam Week 12 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is 1 hour postpartum and observes a large amount of lochia rubra and several small clots on the client’s perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Document the findings and continue to monitor the client. At 1 hour postpartum, it is normal to have lochia rubra and small clots as the uterus is contracting to expel the placenta fragments. The firm, midline fundus at the umbilicus indicates proper involution. There is no indication of excessive bleeding or abnormal fundal position, so there is no immediate concern.
Therefore, the nurse should document the findings to establish a baseline and continue to monitor the client for any changes.
Choice A is incorrect because there is no indication to notify the provider at this time.
Choice B is unnecessary as the fundus is already firm.
Choice C is not the priority as the fundus position and consistency are appropriate. Monitoring and documentation are essential in this situation to detect any deviations from normal postpartum progress.
Question 2 of 5
The nurse is caring for a newly delivered breast-feeding infant. Which nursing intervention would best prevent jaundice in this infant?
Correct Answer: C
Rationale: The correct answer is C: Encouraging the mother to breastfeed the infant every 2 to 3 hours. Breastfeeding frequently helps prevent jaundice by promoting the excretion of bilirubin through stool. This helps prevent bilirubin buildup in the baby's body, reducing the risk of jaundice. Encouraging frequent breastfeeding also ensures the infant receives adequate hydration, which aids in the elimination of bilirubin.
Choice A is incorrect because supplementing with formula can interfere with breastfeeding and affect bilirubin excretion.
Choice B is incorrect because keeping the infant NPO can lead to dehydration and decreased bilirubin excretion.
Choice D is incorrect because phototherapy is a treatment for jaundice, not prevention.
Question 3 of 5
A nurse is completing the admission assessment of a newborn. Which of the following anatomical landmarks should the nurse use when measuring the newborn’s chest circumference?
Correct Answer: D
Rationale: The correct answer is D: Nipple line. When measuring a newborn's chest circumference, the nurse should use the nipple line as the anatomical landmark. This is because the nipple line is a consistent and reliable reference point for chest measurements in newborns. The other choices are not suitable landmarks for chest circumference measurement in newborns. A: Intercostal space is not a specific point for measurement. B: Xiphoid process is too low and not commonly used for chest measurements. C: Sternal notch is not a precise point for chest circumference measurement in newborns.
Therefore, D: Nipple line is the most appropriate anatomical landmark for accurate chest circumference measurement in newborns.
Question 4 of 5
The nurse is informed that a newborn infant with Apgar scores of 1 and 4 will be brought to the neonatal intensive care unit (NICU). The nurse determines that which intervention is the priority?
Correct Answer: B
Rationale: The correct answer is B: Connecting the resuscitation bag to oxygen. This intervention is the priority because the infant has low Apgar scores, indicating poor oxygenation and respiratory effort. Providing oxygen through the resuscitation bag will help improve oxygenation and support the infant's breathing, which is crucial in the immediate postnatal period.
Turning on the apnea and cardiorespiratory monitor (
Choice
A) may be important for continuous monitoring but addressing the oxygenation issue takes precedence. Setting up the radiant warmer control temperature (
Choice
C) is important for maintaining the infant's body temperature but not the immediate priority. Preparing for IV insertion with D5W (
Choice
D) is not necessary at this moment as the priority is to address the respiratory distress.
Question 5 of 5
A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Document this as an expected finding. In a newborn, a heart rate of 130/min is within the normal range (120-160/min). The nurse does not need to take any immediate action as this heart rate is considered normal for a newborn. Documenting this finding is important for ongoing assessment and continuity of care.
Choice A is incorrect because there is no indication for transport to the NICU based solely on the heart rate.
Choice B is unnecessary as further assessment is not warranted for a normal heart rate.
Choice C is not needed as the nurse is capable of accurately assessing the heart rate.