ATI RN
ATI Capstone Class Exam Week 12 Questions
Extract:
Question 1 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 Apgar score is calculated as: Appearance (1 for pink trunk/head, bluish extremities), Pulse (2 for heart rate 130/min), Grimace (1 for weak cry), Activity (1 for flexed extremities), Respiration (1 for weak cry), totaling 6. Higher scores require stronger responses or full pink color.
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 preparing to administer magnesium sulfate to a client. Which of the following is the priority nursing assessment for this client?
Correct Answer: B
Rationale: Respiratory rate is critical when administering magnesium sulfate due to the risk of respiratory depression. This takes priority over bowel sounds, temperature, or fetal heart rate, which are less immediate concerns.
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 Apgar score is calculated as: Appearance (1 for pink trunk/head, bluish extremities), Pulse (2 for heart rate 130/min), Grimace (1 for weak cry), Activity (1 for flexed extremities), Respiration (1 for weak cry), totaling 6. Higher scores require stronger responses or full pink color.
Question 5 of 5
A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following interventions should the nurse include in the plan of care?
Correct Answer: A
Rationale: Monitoring blood glucose is critical for SGA newborns due to high hypoglycemia risk from limited glycogen stores. Intake/output, weight, and temperature are important but secondary to preventing hypoglycemia complications.