ATI RN
ATI Capstone Week 11 Exam Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is scheduled for a maternal serum alpha-fetoprotein test at 15 weeks of gestation. The nurse provides which of the following explanations about this test to the client?
Correct Answer: C
Rationale: The correct answer is C: This test is a screening test for spinal defects in the fetus. The maternal serum alpha-fetoprotein test is used to screen for neural tube defects such as spina bifida in the fetus. The test measures the levels of alpha-fetoprotein in the mother's blood, which can indicate the presence of such defects. At 15 weeks of gestation, this test is typically done as part of routine prenatal screening.
Explanation for other choices:
A: This test does not identify Rh incompatibility; that is typically determined through other blood tests.
B: While the test may indirectly provide information about fetal well-being, its primary purpose is to screen for spinal defects, not general markers of well-being.
D: Fetal lung maturity is typically assessed using tests such as amniocentesis or ultrasound, not the maternal serum alpha-fetoprotein test.
Question 2 of 5
A nurse is caring for a client at the first prenatal visit who has a BMI of 26.5. The client asks how much weight she should gain during pregnancy. Which of the following responses should the nurse make?
Correct Answer: B
Rationale: The correct response is B: The recommendation for you is about 15 to 25 pounds. This is because a client with a BMI of 26.5 falls into the overweight category, and the recommended weight gain during pregnancy for overweight individuals is 15-25 pounds. This range helps in promoting a healthy pregnancy and reducing the risk of complications. Options A and D suggest weight gain ranges that are higher than recommended for an overweight individual, which could lead to potential health risks. Option C states a fixed rate of 1 pound per week, which may not be suitable for everyone and could lead to excessive weight gain.
Therefore, option B is the most appropriate recommendation for a client with a BMI of 26.5.
Question 3 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 4 of 5
A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is 'not really sure if she is in labor colp or not.' Which of the following should the nurse recognize as a sign of true labor?
Correct Answer: C
Rationale: The correct answer is C: Changes in the cervix. In true labor, the cervix undergoes changes such as effacement (thinning) and dilation (opening). These cervical changes are indicative of the onset of labor and progression towards childbirth. By assessing the cervix, the nurse can determine if the client is indeed in true labor.
Rupture of the membranes (choice
A) may or may not occur in labor, and it alone does not confirm true labor. The pattern of contractions (choice
B) is important but not sufficient to differentiate true labor from false labor. The station of the presenting part (choice
D) refers to the position of the baby's head in relation to the pelvis and is not a definitive sign of true labor.
Question 5 of 5
A nurse is providing home safety information for an older adult client who uses a cane. Which of the following statements should the nurse include in the teaching?
Correct Answer: D
Rationale:
Correct Answer: D - You should advance your weak leg forward to the cane, then move your strong leg.
Rationale: By advancing the weak leg first, the client's center of gravity is more stable, reducing the risk of falls. Moving the strong leg next provides additional support and balance. This sequence ensures proper weight distribution and minimizes the risk of tripping or losing balance.
Summary of Incorrect
Choices:
A: Advancing the cane too far ahead can lead to imbalance and potential falls.
B: Holding the cane in the weak hand may not provide adequate support and stability.
C: The cane's height should align with the wrist crease, not the mid flank, for proper use and support.