ATI RN
ATI Capstone Class Exam Week 12 Questions
Extract:
Question 1 of 5
A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn’s mother asks about the swollen area on her son’s head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse?
Correct Answer: B
Rationale: The correct answer is B: A caput succedaneum will subside in a few days. A caput succedaneum is a diffuse swelling of the scalp that occurs due to pressure on the baby's head during labor. It typically resolves on its own within a few days. In this scenario, since the swelling crosses the suture line, it is likely a caput succedaneum. Palpation of the swelling helps to differentiate it from cephalohematoma, which is confined by suture lines.
Choice A is incorrect because a cephalohematoma is a collection of blood between the periosteum and skull bone, not the same as caput succedaneum.
Choices C and D are incorrect as they refer to different conditions unrelated to the swelling on the newborn's head.
Question 2 of 5
The nurse is caring for a newly delivered breast-feeding infant. Which nursing intervention would best prevent jaundice in this infant?
Correct Answer: C
Rationale: The correct answer is C: Encouraging the mother to breastfeed the infant every 2 to 3 hours. Breastfeeding frequently helps prevent jaundice by promoting the excretion of bilirubin through stool. This helps prevent bilirubin buildup in the baby's body, reducing the risk of jaundice. Encouraging frequent breastfeeding also ensures the infant receives adequate hydration, which aids in the elimination of bilirubin.
Choice A is incorrect because supplementing with formula can interfere with breastfeeding and affect bilirubin excretion.
Choice B is incorrect because keeping the infant NPO can lead to dehydration and decreased bilirubin excretion.
Choice D is incorrect because phototherapy is a treatment for jaundice, not prevention.
Question 3 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: The Moro reflex is a startle reflex observed in newborns.
To elicit this reflex, a sudden loud noise or movement is needed. Performing a sharp hand clap near the infant is the appropriate action to trigger the Moro reflex. This action mimics a sudden loud noise, causing the baby to extend the arms and legs, then bring them back in a hugging motion. Placing a finger at the base of the newborn's toes (
Choice
A) does not elicit the Moro reflex. Turning the newborn's head quickly to one side (
Choice
B) triggers the asymmetric tonic neck reflex, not the Moro reflex. Holding the newborn vertically allowing one foot to touch the table surface (
Choice
C) elicits the stepping reflex, not the Moro reflex.
Question 4 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: The correct answer is D: Disseminated intravascular coagulation (DI
C). Abruptio placentae can lead to DIC due to the release of tissue factor, causing widespread clotting and consumption of clotting factors, leading to bleeding. Petechiae and bleeding around the IV site are signs of DIC. Preeclampsia (choice
A) is a condition characterized by hypertension and proteinuria. Puerperal infection (choice
B) is an infection that occurs after childbirth. Anaphylactoid syndrome of pregnancy (choice
C) is a rare complication associated with amniotic fluid embolism. These complications are not directly related to the signs and symptoms described in the scenario.
Question 5 of 5
A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn’s mother asks about the swollen area on her son’s head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse?
Correct Answer: B
Rationale: The correct answer is B: A caput succedaneum will subside in a few days. A caput succedaneum is a diffuse swelling of the scalp that occurs due to pressure on the baby's head during labor. It typically resolves on its own within a few days. In this scenario, since the swelling crosses the suture line, it is likely a caput succedaneum. Palpation of the swelling helps to differentiate it from cephalohematoma, which is confined by suture lines.
Choice A is incorrect because a cephalohematoma is a collection of blood between the periosteum and skull bone, not the same as caput succedaneum.
Choices C and D are incorrect as they refer to different conditions unrelated to the swelling on the newborn's head.