ATI RN
ATI Capstone Class Exam Week 12 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is postpartum and finds the fundus slightly displaced to the right. Based on these findings, which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Assist the client to the bathroom to void. This action helps to empty the bladder, which can reduce uterine displacement. A full bladder can push the uterus to one side. Moving the client to the left lateral position (choice
A) may not address the underlying issue of a full bladder. Kegel exercises (choice
B) are not directly related to fundal displacement. Asking the client to rate her pain (choice
D) is not relevant to the situation at hand.
Question 2 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: The correct answer is A: Drying the newborn's skin thoroughly. When a newborn is born, they are wet and evaporative heat loss occurs as the moisture on their skin evaporates, leading to cooling. Drying the newborn's skin thoroughly helps reduce this heat loss by preventing the moisture from evaporating. Preventing air drafts (
B) and placing the newborn on a warm surface (
C) can help with overall thermal regulation but do not specifically target evaporative heat loss. Maintaining ambient room temperature at 24°C (75.2°F) (
D) is important for thermoregulation but does not directly address evaporative heat loss.
Question 3 of 5
A nurse in a provider’s office is caring for a client who is at 36 weeks of gestation and scheduled for an amniocentesis. The client asks why she is having an ultrasound prior to the procedure. Which of the following is an appropriate response by the nurse?
Correct Answer: A
Rationale:
Correct Answer: A
Rationale: Prior to amniocentesis, an ultrasound is done to identify the location of the placenta and fetus. This is crucial to ensure the safety of the procedure. It helps in determining the best site for needle insertion to avoid harming the fetus or placenta. Additionally, it allows for visualization of any abnormalities that could affect the amniocentesis procedure.
Summary of other choices:
B: Estimating fetal age is not the primary purpose of the ultrasound before amniocentesis.
C: Screening for spina bifida is usually done through other specific tests, not the ultrasound before amniocentesis.
D: Determining if there is more than one fetus is not the main goal of the ultrasound before amniocentesis.
Question 4 of 5
A nurse is preparing to assess a newborn who is post-term. Which of the following findings should the nurse expect? (Select all that apply)
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D. A post-term newborn is born after 42 weeks of gestation, which can lead to certain physical characteristics.
A: Vernix in the folds and creases is expected in post-term newborns due to prolonged exposure to amniotic fluid.
C: Positive Moro reflex is expected as it indicates the baby's neurological maturity.
D: Cracked peeling skin is common in post-term newborns due to prolonged exposure to amniotic fluid, leading to dryness.
B: Abundant lanugo is typically seen in premature newborns rather than post-term.
E: Short soft fingernails are not specific to post-term newborns.
Question 5 of 5
A nurse is preparing to administer vitamin K by IM injection to a newborn. The nurse should administer the medication into which of the following muscles?
Correct Answer: B
Rationale: The correct answer is B: Vastus lateralis. This muscle is the preferred site for IM injections in infants due to its large muscle mass and minimal risk of injury to nerves and blood vessels. The dorsogluteal site (choice
A) is not recommended for neonates due to the risk of damaging the sciatic nerve. The deltoid muscle (choice
C) is not suitable for newborns as it lacks adequate muscle mass and can lead to nerve injury. The ventrogluteal site (choice
D) can be used in older infants but is not the preferred site for newborns.