ATI LPN
PN ATI Capstone Maternal Newborn
1. A client who gave birth 12 hours ago is experiencing excessive vaginal bleeding. Which of the following findings indicates the client is experiencing decreased cardiac output?
- A. Bradycardia
- B. Flushed face
- C. Hypotension
- D. Polyuria
Correct answer: C
Rationale: Hypotension is a key indicator of decreased cardiac output, especially in the context of postpartum hemorrhage, which can lead to significant fluid volume loss and compromise perfusion. In this scenario, the excessive vaginal bleeding could lead to hypovolemia, resulting in decreased cardiac output and subsequent hypotension. Bradycardia (choice A) is not typically associated with decreased cardiac output in this scenario, as the body often compensates for decreased cardiac output by increasing heart rate. A flushed face (choice B) may indicate vasodilation but is not a direct indicator of decreased cardiac output. Polyuria (choice D) is excessive urination and is not a specific indicator of decreased cardiac output in this context.
2. A healthcare professional is preparing to administer a dose of hydrocodone. Which of the following should the healthcare professional assess first?
- A. Respiratory rate
- B. Blood pressure
- C. Pain level
- D. Heart rate
Correct answer: A
Rationale: When administering hydrocodone, a healthcare professional should assess the respiratory rate first because hydrocodone is an opioid that can lead to respiratory depression. Monitoring the respiratory rate helps to detect any signs of respiratory distress or depression early on. Assessing blood pressure, pain level, or heart rate is also important but not the priority when administering hydrocodone, as the risk of respiratory depression is a more critical concern.
3. A nurse is providing education to a client in the first trimester of pregnancy. What information should the nurse include regarding the cause of indigestion and heartburn?
- A. Estrogen causes increased appetite
- B. Progesterone causes relaxation of the cardiac sphincter allowing acid to reflux
- C. HCG hormone leads to increased gastric acidity
- D. The uterus compresses the stomach early in pregnancy
Correct answer: B
Rationale: The correct answer is B. Progesterone causes relaxation of the smooth muscles in the body, including the cardiac sphincter. This relaxation allows stomach acid to reflux into the esophagus, leading to heartburn during pregnancy. Choices A, C, and D are incorrect because they do not directly relate to the physiological mechanism that causes heartburn during pregnancy. Estrogen causing increased appetite (Choice A) is not directly linked to heartburn. HCG hormone increasing gastric acidity (Choice C) is not the primary cause of heartburn during pregnancy. The uterus compressing the stomach early in pregnancy (Choice D) may contribute to feelings of fullness or bloating but is not the main cause of heartburn.
4. A client at 38 weeks gestation with a history of herpes simplex virus 2 is being admitted. Which of the following questions is most appropriate to ask the client?
- A. Have your membranes ruptured?
- B. Do you have any active lesions?
- C. Are you positive for beta strep?
- D. How far apart are your contractions?
Correct answer: B
Rationale: The most appropriate question to ask a client with a history of herpes simplex virus 2 at 38 weeks gestation is whether they have any active lesions. Active herpes lesions during labor can necessitate a cesarean delivery to prevent neonatal transmission. Asking about ruptured membranes (choice A), beta strep status (choice C), or contraction timing (choice D) is important but not the priority when managing a client with a history of herpes simplex virus 2 due to the high risk of neonatal transmission.
5. A client with multiple sclerosis reports diplopia. Which of the following actions should the nurse take?
- A. Encourage the client to focus on a distant object.
- B. Apply a warm compress to the client’s eyes.
- C. Recommend alternating eye patches during the day.
- D. Administer artificial tears.
Correct answer: C
Rationale: The correct action for the nurse to take when caring for a client with multiple sclerosis reporting diplopia is to recommend alternating eye patches during the day. This strategy can help relieve diplopia (double vision) by allowing each eye to rest alternately, reducing eye strain. Encouraging the client to focus on a distant object (Choice A) is not an appropriate intervention for diplopia in this case. Applying a warm compress to the client's eyes (Choice B) and administering artificial tears (Choice D) are not effective interventions for diplopia associated with multiple sclerosis.
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