ATI RN
ATI Capstone Week 11 Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?
Correct Answer: B
Rationale: The correct answer is B: Ask the client to turn onto her side. This is the correct intervention because the client's low blood pressure reading of 82/52 mm Hg indicates hypotension, which can be caused by aortocaval compression in the supine position. Turning the client onto her side will help alleviate this compression, improve blood flow, and prevent further complications.
Choice A (Prepare for a cesarean birth) is incorrect because there is no indication for a cesarean birth solely based on the blood pressure reading.
Choice C (Assist the client to an upright position) is incorrect as it may worsen hypotension due to gravitational pooling of blood.
Choice D (Prepare for an immediate vaginal delivery) is incorrect as the client is at 6 cm dilation, not fully dilated, and immediate delivery is not warranted based on the blood pressure reading.
Question 2 of 5
A nurse is collecting data from a child who is descending stairs by placing both feet on each step and holding on to the railing. The nurse should understand that these actions are developmentally appropriate at which of the following ages?
Correct Answer: A
Rationale: The correct answer is A: 3 years. At around 3 years old, children typically start descending stairs by placing both feet on each step and holding onto the railing for support. This is developmentally appropriate as it shows they have developed the coordination and balance to navigate stairs safely. At 6 years old (choice
B), children should already be able to descend stairs without needing to place both feet on each step.
Choices C (5 years) and D (4 years) are also incorrect as children at these ages should be displaying more advanced stair-descending skills compared to placing both feet on each step.
Question 3 of 5
A school nurse conducting a screening for pediculosis capitis identifies several children who require treatment. Which of the following instructions should the nurse give the children’s parents?
Correct Answer: B
Rationale: The correct answer is B: Seal nonwashable items in airtight plastic bags. This instruction is important to prevent the spread of head lice by isolating infested items. By sealing nonwashable items, such as stuffed animals or pillows, in airtight bags, the lice will eventually die off without being able to transfer to other individuals. This method helps contain the infestation and stop it from spreading.
Incorrect choices:
A: Spray countertops and sinks with insecticide - This is unnecessary and potentially harmful to children.
C: Inspect any dogs or cats at home for lice - Head lice are species-specific and do not infest pets.
D: Soak all combs and hairbrushes in alcohol - While cleaning combs and hairbrushes is important, soaking them in alcohol is excessive and can damage the items.
Question 4 of 5
A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?
Correct Answer: B
Rationale: The correct answer is B: Ask the client to turn onto her side. This is the correct intervention because the client's low blood pressure reading of 82/52 mm Hg indicates hypotension, which can be caused by aortocaval compression in the supine position. Turning the client onto her side will help alleviate this compression, improve blood flow, and prevent further complications.
Choice A (Prepare for a cesarean birth) is incorrect because there is no indication for a cesarean birth solely based on the blood pressure reading.
Choice C (Assist the client to an upright position) is incorrect as it may worsen hypotension due to gravitational pooling of blood.
Choice D (Prepare for an immediate vaginal delivery) is incorrect as the client is at 6 cm dilation, not fully dilated, and immediate delivery is not warranted based on the blood pressure reading.
Question 5 of 5
A nurse is orienting a newly licensed nurse in the care of an infant who has myelomeningocele. Which of the following actions by the new nurse indicates the teaching has been effective?
Correct Answer: C
Rationale: The correct answer is C. Maintaining a dry dressing over the sac of an infant with myelomeningocele is crucial to prevent infection and promote healing. Placing the infant in a side-lying position (
A) is generally recommended but not specific to myelomeningocele care. Performing range of motion on the infant's hips (
B) is important for overall mobility but not directly related to myelomeningocele care. Taking an axillary temperature (
D) is a routine nursing task but not specific to this situation.