ATI RN
ATI Capstone Class Exam Week 12 Questions
Extract:
Question 1 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: The correct answer is B. Deep tendon reflexes of 1+ are inconsistent with preeclampsia. In preeclampsia, deep tendon reflexes are typically hyperactive (3+ or 4+). This is due to the central nervous system irritability caused by hypertension.
Therefore, a reflex of 1+ suggests normal reflexes, which is not expected in preeclampsia. Other choices A, C, and D are consistent with preeclampsia. Proteinuria (choice
A) is a hallmark sign of preeclampsia. Elevated blood pressure (choice
C) is a common finding in preeclampsia. Pitting edema (choice
D) is also commonly observed in preeclampsia due to fluid retention.
Question 2 of 5
A nurse is preparing to administer magnesium sulfate to a client. Which of the following is the priority nursing assessment for this client?
Correct Answer: B
Rationale: The correct answer is B: Respiratory rate. Magnesium sulfate is a medication that can cause respiratory depression. Monitoring the client's respiratory rate is crucial to detect any signs of respiratory distress or depression promptly. This assessment is a priority because respiratory depression can lead to serious complications, including respiratory arrest. Assessing bowel sounds (choice
A), temperature (choice
C), and fetal heart rate (choice
D) are important but not as critical as monitoring the respiratory rate when administering magnesium sulfate. Bowel sounds may indicate gastrointestinal motility issues, temperature changes may indicate infection, and fetal heart rate is important in pregnancy but not the priority when administering magnesium sulfate.
Question 3 of 5
A nurse in the ambulatory surgery center is providing discharge teaching to a client who had a dilation and curettage (D&C) following a spontaneous miscarriage. Which of the following should be included in the teaching?
Correct Answer: C
Rationale: The correct answer is C: Vaginal intercourse can be resumed after 2 weeks. This is important to prevent infection and allow the cervix to heal.
Choice A is incorrect as products of conception are typically expelled during the D&C procedure.
Choice B is irrelevant as zinc intake is not directly related to post-D&C care.
Choice D is incorrect as aspirin can increase the risk of bleeding post-D&C.
Question 4 of 5
A male newborn infant has just been circumcised. The nurse checks the surgical site, expecting it to have what appearance?
Correct Answer: C
Rationale: The correct answer is C: Reddened with a scant amount of yellow exudate. After circumcision, it is normal for the surgical site to appear reddened due to the inflammatory response. The presence of a scant amount of yellow exudate indicates normal wound healing with minimal discharge. This is a sign of the body's natural process of cleansing the wound.
Choices A and D are incorrect because copious blood or bloody drainage would be abnormal and may indicate bleeding complications.
Choice B is incorrect as pink without drainage would not be expected immediately after circumcision. In choice A, while some bloody drainage may be expected, the presence of yellow exudate is more indicative of normal healing.
Question 5 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.