ATI RN
ATI Capstone Class Exam Week 12 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?
Correct Answer: D
Rationale: Inserting a gloved hand to relieve cord pressure prevents fetal hypoxia, the immediate priority in cord prolapse. Covering the cord, positioning, or preparing for birth are secondary to ensuring fetal oxygenation.
Question 2 of 5
A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Moro reflex, the nurse should take which of the following actions?
Correct Answer: D
Rationale: A sharp hand clap triggers the Moro reflex, causing the newborn to extend and abduct arms.
Toe stimulation elicits the Babinski reflex, head-turning elicits the tonic neck reflex, and foot contact elicits the stepping reflex.
Question 3 of 5
A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following interventions should the nurse include in the plan of care?
Correct Answer: A
Rationale: Monitoring blood glucose is critical for SGA newborns due to high hypoglycemia risk from limited glycogen stores. Intake/output, weight, and temperature are important but secondary to preventing hypoglycemia complications.
Question 4 of 5
A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The client’s ultrasound examination indicates that the fetus is small for gestational age (SGA). Which of the following interventions should the nurse include in the plan of care after birth?
Correct Answer: A
Rationale: SGA newborns are at risk for meconium aspiration syndrome, requiring observation for meconium in respiratory secretions. They are prone to hypothermia, not hyperthermia; anemia is less immediate; and hypoglycemia, not hyperglycemia, is a concern.
Question 5 of 5
A nurse on the labor and delivery unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?
Correct Answer: A
Rationale: Drying the newborn’s skin prevents evaporative heat loss by removing amniotic fluid that cools the skin. Preventing drafts reduces convective loss, a warm surface reduces conductive loss, and room temperature addresses radiant loss.