ATI RN
ATI Capstone Week 11 Exam Questions
Extract:
Question 1 of 5
A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 min and a frequency of 3 min. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min and maternal blood pressure 92/54 mm Hg. Which of the following is the priority action for the nurse to take?
Correct Answer: D
Rationale: The correct answer is D: Place the client in a lateral position. This is the priority action because the client's low blood pressure (92/54 mm Hg) indicates hypotension, which could be causing decreased perfusion to the fetus. Placing the client in a lateral position can help improve blood flow to the placenta and fetus. This position can also help alleviate pressure on the vena cava, improving maternal cardiac output.
Choice A (Have the client void) is not the priority action in this case as the client's vital signs indicate a more urgent concern related to hypotension and fetal well-being.
Choice B (Ask the client if she needs pain medication) is not the priority as addressing pain relief is important but not as urgent as addressing potential hypotension.
Choice C (Notify the provider of the findings) may be necessary but is not the immediate priority.
In summary, placing the client in a lateral position is the priority action to address hypotension
Question 2 of 5
A nurse is assessing a client who is receiving liothyronine for treatment of hypothyroidism. The nurse should recognize which of the following findings as a therapeutic response to this medication?
Correct Answer: C
Rationale: The correct answer is C: Increase in energy. Liothyronine is a thyroid hormone replacement therapy used to treat hypothyroidism. Thyroid hormones play a key role in regulating metabolism and energy levels in the body.
Therefore, an increase in energy is a therapeutic response to liothyronine as it indicates that the medication is effectively restoring thyroid hormone levels to normal.
Incorrect choices:
A: Increase in weight - Hypothyroidism is often associated with weight gain, so with effective treatment like liothyronine, weight gain should decrease or stabilize.
B: Decrease in body temperature - Hypothyroidism can lead to feeling cold, so with proper treatment, body temperature should normalize.
D: Decreased heart rate - Hypothyroidism can cause a slow heart rate, so with treatment, the heart rate should increase towards normal levels.
Question 3 of 5
A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?
Correct Answer: B
Rationale: The correct answer is B: 3 cm above the umbilicus. At 22 weeks of gestation, the fundus should be palpable at approximately the level of the umbilicus or slightly above. As the uterus grows with the developing fetus, the fundal height increases. This location corresponds to the expected fundal height for a pregnancy at 22 weeks.
Choice A (Slightly above the umbilicus) is incorrect as it does not specify the exact measurement.
Choices C (3 cm below the umbilicus) and D (Slightly below the umbilicus) are incorrect because the fundus should be higher at 22 weeks.
Question 4 of 5
A nurse is caring for a client at the first prenatal visit who has a BMI of 26.5. The client asks how much weight she should gain during pregnancy. Which of the following responses should the nurse make?
Correct Answer: B
Rationale: The correct response is B: The recommendation for you is about 15 to 25 pounds. This is because a client with a BMI of 26.5 falls into the overweight category, and the recommended weight gain during pregnancy for overweight individuals is 15-25 pounds. This range helps in promoting a healthy pregnancy and reducing the risk of complications. Options A and D suggest weight gain ranges that are higher than recommended for an overweight individual, which could lead to potential health risks. Option C states a fixed rate of 1 pound per week, which may not be suitable for everyone and could lead to excessive weight gain.
Therefore, option B is the most appropriate recommendation for a client with a BMI of 26.5.
Question 5 of 5
A nurse is caring for several clients who are at various developmental stages. The nurse should explain that, according to Erikson, acceptance of death is a primary task of which of the following stages of psychosocial development?
Correct Answer: B
Rationale: The correct answer is B: Integrity vs. despair. According to Erikson's psychosocial development theory, the stage of Integrity vs. Despair occurs in late adulthood. During this stage, individuals reflect on their lives and come to terms with their mortality, accepting the reality of death. This acceptance leads to a sense of integrity and wisdom. Other options do not specifically address acceptance of death. A: Identity vs. role diffusion focuses on forming a sense of self. C: Generativity vs. stagnation involves contributing to society. D: Autonomy vs. shame and doubt pertains to developing independence.