ATI LPN
PN ATI Capstone Maternal Newborn
1. A postpartum client's fundus is firm, 3 cm above the umbilicus, and displaced to the right. Which of the following interventions should the nurse take?
- A. Massage the fundus
- B. Administer oxytocin
- C. Assist the client to void then reassess the fundus
- D. Notify the healthcare provider
Correct answer: C
Rationale: The correct intervention for a postpartum client with a firm, displaced fundus is to assist the client to void then reassess the fundus. Displacement of the uterus to the right is often a sign of bladder distention, which can prevent the uterus from contracting properly and increase the risk of postpartum hemorrhage. By helping the client to void, the nurse can alleviate the bladder distention, allowing the uterus to contract effectively. Massaging the fundus (Choice A) may not address the underlying issue of bladder distention. Administering oxytocin (Choice B) is not indicated without assessing and addressing the cause of the displacement. Notifying the healthcare provider (Choice D) is premature before implementing initial nursing interventions to address the potential cause of the displaced fundus.
2. Following delivery, the nurse places the newborn under a radiant heat warmer. Which of the following is this action used to prevent?
- A. Cold stress
- B. Hyperthermia
- C. Dehydration
- D. Hypoxia
Correct answer: A
Rationale: Placing the newborn under a radiant heat warmer is used to prevent cold stress. Cold stress in newborns can lead to increased oxygen consumption and energy expenditure as the body tries to maintain its temperature, potentially resulting in hypoglycemia and metabolic acidosis if not addressed. The radiant warmer helps maintain the infant's body temperature, reducing the risk of cold stress and its complications. Choices B, C, and D are incorrect because the primary purpose of using a radiant warmer in this scenario is to prevent cold stress specifically, not hyperthermia, dehydration, or hypoxia.
3. A client has been prescribed raloxiphene. As the nurse, you know that raloxiphene is used to treat:
- A. Migraines
- B. Hypertension
- C. Osteoporosis
- D. Heart disease
Correct answer: C
Rationale: Raloxiphene (Evista) is a selective estrogen receptor modulator (SERM) used primarily to prevent and treat osteoporosis in postmenopausal women. It helps to maintain bone density and reduce the risk of fractures by mimicking the effects of estrogen on bone tissue. It is not indicated for the treatment of migraines, hypertension, or heart disease. Therefore, the correct answer is osteoporosis (Choice C). Choices A, B, and D are incorrect as raloxiphene is not used to treat migraines, hypertension, or heart disease.
4. A nurse is caring for a laboring client and notes that the fetal heart rate begins to decelerate after the contraction has started. The lowest point of deceleration occurs after the peak of the contraction. What is the priority nursing action?
- A. Administer oxygen
- B. Change the client's position
- C. Increase IV fluids
- D. Call the healthcare provider
Correct answer: B
Rationale: Late decelerations are caused by uteroplacental insufficiency, indicating that the fetus is not receiving adequate oxygen during contractions. This is an emergency that requires prompt intervention. Changing the client's position helps improve placental blood flow, reducing stress on the fetus. Administering oxygen may be necessary if changing position does not resolve the decelerations. Increasing IV fluids is not the priority in this situation as it won't directly address the cause of late decelerations. Calling the healthcare provider should be done after immediate interventions like changing the client's position have been implemented and assessed.
5. A nurse is caring for a newborn with hyperbilirubinemia. Which of the following interventions should be taken during phototherapy?
- A. Maintain an eye mask over the newborn's eyes
- B. Feed the newborn every hour
- C. Monitor the newborn's temperature
- D. Administer vitamin K
Correct answer: A
Rationale: During phototherapy for a newborn with hyperbilirubinemia, it is crucial to maintain an eye mask over the newborn's eyes. The purpose of the eye mask is to protect the infant's eyes from potential damage caused by the intense light used in phototherapy. While feeding the newborn frequently and monitoring temperature are essential aspects of newborn care, they are not specific to phototherapy. Administering vitamin K is important for newborns to prevent bleeding disorders but is not directly related to phototherapy for hyperbilirubinemia.
Access More Features
ATI LPN Basic
$69.99/ 30 days
- 50,000 Questions with answers
- All ATI courses Coverage
- 30 days access
ATI LPN Premium
$149.99/ 90 days
- 50,000 Questions with answers
- All ATI courses Coverage
- 90 days access