ATI RN
ATI Capstone Class Exam Week 12 Questions
Extract:
Question 1 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 2 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: A displaced fundus, often due to a full bladder, requires assisting the client to void to reposition the uterus and reduce hemorrhage risk. Lateral positioning, Kegel exercises, or pain assessment don’t address the cause.
Question 3 of 5
A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?
Correct Answer: B
Rationale: Deep tendon reflexes of 1+ are inconsistent with preeclampsia, which typically causes hyperreflexia (3+ or 4+). Proteinuria, high blood pressure, and edema are consistent with preeclampsia.
Question 4 of 5
A nurse in a provider’s office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?
Correct Answer: C
Rationale: Hypertension is the most common risk factor for placental abruption, as it can damage placental blood vessels, leading to premature separation. Cocaine use, trauma, and smoking are risk factors but are less common than hypertension.
Question 5 of 5
A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications?
Correct Answer: D
Rationale: Petechiae and bleeding suggest disseminated intravascular coagulation (DI
C), a complication of abruptio placentae due to clotting factor consumption. Preeclampsia involves hypertension, puerperal infection involves fever, and anaphylactoid syndrome involves sudden collapse, not matching these signs.