ATI RN
ATI Capstone Week 11 Exam Questions
Extract:
Question 1 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.
Question 2 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 3 of 5
A nurse is caring for a child who is on a clear liquid diet. At lunch, the child consumed 1/2 cup of juice, 3 oz gelatin, 1 oz of an ice pop, and 20 mL ginger ale. How many mL should the nurse record as the child's fluid intake?
Correct Answer: 260
Rationale: The correct answer is 260 mL.
To calculate the child's fluid intake, we need to convert all measurements to mL. 1/2 cup of juice is approximately 120 mL, 3 oz of gelatin is approximately 90 mL, 1 oz of an ice pop is approximately 30 mL, and 20 mL of ginger ale. Adding these amounts together (120 + 90 + 30 + 20) gives a total of 260 mL. This is the total fluid intake the nurse should record for the child. Other choices are incorrect because they do not accurately reflect the total fluid intake based on the given measurements.
Question 4 of 5
A nurse is teaching about fetal development to a group of clients in the antenatal clinic. Which of the following statements should the nurse include in the teaching?
Correct Answer: B
Rationale: The correct answer is B because the baby's heart begins to beat around 5 weeks of pregnancy and is usually audible by a Doppler stethoscope at 12 weeks. This is important for monitoring fetal well-being.
Choice A is incorrect because fetal movements are usually felt by the mother around week 18-20.
Choice C is incorrect because lanugo typically covers the baby's body around week 20 and usually sheds before birth.
Choice D is incorrect because the sex of the baby is determined at conception, but it is usually revealed through ultrasound around week 20.
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.