ATI LPN
PN ATI Capstone Maternal Newborn
1. A nurse is assessing a client who is at 31 weeks of gestation. Which of the following findings should the nurse identify as an indication of a potential prenatal complication?
- A. Periodic tingling of fingers
- B. Absence of clonus
- C. Leg cramps
- D. Blurred vision
Correct answer: D
Rationale: Blurred vision can be an indicator of serious conditions such as preeclampsia, which involves hypertension and can lead to significant maternal and fetal complications. Periodic tingling of fingers, absence of clonus, and leg cramps are common discomforts during pregnancy but are not typically associated with serious prenatal complications like preeclampsia. Therefore, the correct answer is D.
2. A nurse is caring for a client who has been receiving oxytocin IV for labor augmentation. The client's contractions are occurring every 2 minutes and lasting 90 seconds. What action should the nurse take?
- A. Decrease the oxytocin infusion
- B. Discontinue the oxytocin infusion
- C. Increase the IV fluid rate
- D. Apply an internal fetal monitor
Correct answer: B
Rationale: The correct action for the nurse to take in this situation is to discontinue the oxytocin infusion. The client is experiencing uterine hyperstimulation, as evidenced by contractions occurring every 2 minutes and lasting 90 seconds. Discontinuing the oxytocin is crucial to prevent fetal distress and uterine rupture. Increasing the IV fluid rate would not address the uterine hyperstimulation caused by oxytocin. Applying an internal fetal monitor is not the priority at this moment; first, the oxytocin infusion needs to be stopped to manage the uterine hyperstimulation effectively.
3. A healthcare provider is providing education to a client about atorvastatin. Which of the following should be included?
- A. Monitor for muscle pain
- B. Avoid sun exposure
- C. Report any gastrointestinal symptoms
- D. Check liver function tests
Correct answer: A
Rationale: Corrected Rationale: Atorvastatin can cause muscle pain and liver function abnormalities. Monitoring for muscle pain is essential as it can be a sign of a serious side effect called rhabdomyolysis. While liver function tests are necessary before starting atorvastatin, checking them continuously may not be required. Avoiding sun exposure and reporting gastrointestinal symptoms are not directly associated with atorvastatin use.
4. A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client?
- A. Contact
- B. Droplet
- C. Protective
- D. Airborne
Correct answer: D
Rationale: The correct answer is D: Airborne. Tuberculosis is spread through small droplets that remain airborne for longer periods, hence requiring airborne precautions. Choice A - Contact precautions are used for diseases spread by direct or indirect contact. Choice B - Droplet precautions are for diseases transmitted by large respiratory droplets that can travel short distances. Choice C - Protective isolation is not necessary for tuberculosis, as it is not spread through contact with the client.
5. A client in labor has an epidural for pain control. Which of the following clinical manifestations is an adverse effect of epidural anesthesia?
- A. Polyuria
- B. Hypertension
- C. Pruritus
- D. Dry mouth
Correct answer: C
Rationale: Pruritus is a common adverse effect of epidural anesthesia, often due to the opioids administered with the epidural. It presents as itching on the skin and can cause significant discomfort to the client. Polyuria (excessive urination) and dry mouth are not typical adverse effects of epidural anesthesia. Hypertension is not commonly associated with epidural anesthesia; in fact, hypotension is a more frequent complication due to sympathetic blockade. Therefore, the correct answer is pruritus (choice C), as it is a known adverse effect of epidural anesthesia.
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