ATI RN
ATI Capstone Class Exam Week 12 Questions
Extract:
Question 1 of 5
A nurse is monitoring a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three fingerbreadths below the umbilicus, lochia rubra is moderate, and the breasts are full and warm to palpation. Which of the following interpretations of these findings should the nurse make?
Correct Answer: A
Rationale: The findings are normal: fundus descending, moderate lochia rubra, and full, warm breasts indicate milk production. No interventions are needed, as heating pads, bra removal, or mastitis signs (pain, fever) are not indicated.
Question 2 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 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: 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 4 of 5
An 8-pound 15-ounce baby born at 35 weeks’ gestation would be described using which terminology? Select all that apply.
Correct Answer: C,D
Rationale: At 35 weeks, the baby is preterm (before 37 weeks). An 8-pound 15-ounce weight is average for gestational age (AG
A), within the 10th-90th percentiles. The baby is not small for gestational age, term, or post-term.
Question 5 of 5
A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?
Correct Answer: A
Rationale:
Tocolytics are safe and effective for preterm labor at 26 weeks to delay delivery and improve fetal outcomes. Braxton-Hicks contractions don’t require tocolytics, post-term pregnancy needs induction, and fetal death doesn’t benefit from delaying labor.