ATI RN
ATI Capstone Week 11 Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) is 130 to 150/min, but there has been no fetal movement for 15 min. Which of the following actions should the nurse perform?
Correct Answer: B
Rationale: The correct answer is B: Offering the client a snack of orange juice and crackers. This action is appropriate because it can help stimulate fetal movement due to the natural increase in blood sugar levels from consuming the snack. This may lead to an increase in fetal activity, which is a positive sign during a nonstress test. Encouraging the client to consume a snack is a non-invasive intervention that can potentially improve the test results without causing harm to the client or the fetus. It is important to address the lack of fetal movement promptly, and offering a snack is a safe and effective way to do so.
Incorrect choices:
A: Encouraging the client to walk around without the monitoring unit could potentially disrupt the monitoring process and may not necessarily stimulate fetal movement.
C: Induction of labor is not warranted based solely on the absence of fetal movement for 15 minutes during a nonstress test.
D: Turning the client onto her left side is a common intervention to optimize fetal oxygenation but may
Question 2 of 5
A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which of the following changes should the nurse include in the discussion? (Select all that apply.)
Correct Answer: C,D,E
Rationale: The correct answers are C, D, and E. Aging leads to joint degeneration, weakening the musculoskeletal system. The cough reflex diminishes with age, increasing susceptibility to respiratory infections. Bladder capacity decreases due to weakening bladder muscles. A is incorrect as visual acuity typically decreases with age. B is incorrect as systolic blood pressure tends to increase. F and G are not provided in the question.
Question 3 of 5
A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?
Correct Answer: C
Rationale: Answer C is correct because at 0 station, the lowermost portion of the fetus is at the level of the ischial spines. This indicates that the baby's head has descended to the level of the maternal ischial spines, which is a significant position in the birthing process. This is a key landmark for monitoring progress during labor.
Option A is incorrect because passing through the pelvic outlet is not the same as being at 0 station. Option B is incorrect because the palpability of the posterior fontanel is unrelated to station. Option D is incorrect because the fetal head position is not specified in the station measurement.
Question 4 of 5
A nurse is caring for a child who has Kawasaki disease. Which of the following systems should the nurse monitor for complications in response to this diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Cardiovascular. Kawasaki disease primarily affects the blood vessels, particularly the coronary arteries, leading to potential complications such as coronary artery aneurysms and myocarditis. Monitoring the cardiovascular system is crucial to detect any signs of these serious complications early on.
Choice A: Respiratory is incorrect as Kawasaki disease does not primarily affect the respiratory system.
Choice C: Integumentary is incorrect as this disease does not typically cause significant skin issues.
Choice D: Gastrointestinal is incorrect as gastrointestinal complications are not commonly associated with Kawasaki disease.
In summary, monitoring the cardiovascular system is essential in Kawasaki disease due to its potential impact on coronary arteries, while the other systems are less likely to be affected.
Question 5 of 5
A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding?
Correct Answer: D
Rationale: The correct interpretation is choice D: Variable decelerations are due to umbilical cord compression. Variable decelerations are abrupt decreases in the fetal heart rate that are often V-shaped on the monitor strip. They are typically caused by compression of the umbilical cord, leading to decreased oxygen supply to the fetus. This is a common finding in the first stage of labor and can be managed by changing the mother's position to relieve pressure on the umbilical cord.
Choice A is incorrect because uteroplacental insufficiency typically presents with late decelerations, not variable decelerations.
Choice B is incorrect as fetal head compression usually results in early decelerations.
Choice C is incorrect because IV narcotics may cause late decelerations, not variable decelerations.
In summary, variable decelerations are most commonly caused by umbilical cord compression, not uteroplacental insufficiency, fetal head compression, or IV narcotics.