ATI RN
ATI Capstone Class Exam Week 12 Questions
Extract:
Question 1 of 5
A nurse is completing the admission assessment of a newborn. Which of the following anatomical landmarks should the nurse use when measuring the newborn’s chest circumference?
Correct Answer: D
Rationale: The correct answer is D: Nipple line. When measuring a newborn's chest circumference, the nurse should use the nipple line as the anatomical landmark. This is because the nipple line is a consistent and reliable reference point for chest measurements in newborns. The other choices are not suitable landmarks for chest circumference measurement in newborns. A: Intercostal space is not a specific point for measurement. B: Xiphoid process is too low and not commonly used for chest measurements. C: Sternal notch is not a precise point for chest circumference measurement in newborns.
Therefore, D: Nipple line is the most appropriate anatomical landmark for accurate chest circumference measurement in newborns.
Question 2 of 5
A nurse is completing discharge instructions for a new mother and her 2-day-old newborn. The mother asks, “How will I know if my baby gets enough breast milk?” Which of the following responses should the nurse make?
Correct Answer: A
Rationale: The correct answer is A: Your baby should wet 6 to 8 diapers per day. This is because the frequency of wet diapers indicates that the newborn is getting enough breast milk. An adequate amount of wet diapers signifies that the baby is adequately hydrated and receiving sufficient nourishment. It is a concrete and measurable way to monitor the baby's intake.
Choice B is incorrect because the wake cycle after feeding varies among newborns and is not a reliable indicator of milk intake.
Choice C is incorrect as burping after feeding is a normal process but not necessarily an indicator of sufficient milk intake.
Choice D is incorrect because newborns typically need to feed more frequently than every 6 hours.
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 observes 5 minutes after delivery that a newborn has a pink trunk and head, bluish hands and feet, and a heart rate of 130/min. He has flexed extremities and a weak, slow cry. The nurse should document what Apgar score for this infant?
Correct Answer: B
Rationale: The correct Apgar score for this infant is B: 6. The Apgar score assesses a newborn's overall condition at 1 and 5 minutes after birth based on five criteria: Appearance, Pulse, Grimace, Activity, and Respiration. In this case, the baby has a pink trunk and head (2 points), bluish hands and feet (1 point), a heart rate of 130/min (2 points), flexed extremities (2 points), and a weak, slow cry (1 point). Adding these points together, the Apgar score is 2+1+2+2+1=8. Since the Apgar score ranges from 0 to 10, a score of 6 indicates that the infant may need some assistance but is generally in good condition. Other choices are incorrect because they do not add up correctly based on the described criteria.
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: 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.