ATI RN
ATI Capstone Maternal Newborn Assessment Quizlet
1. A nurse is assessing a client who is in the first stage of labor and has an external fetal monitor in place. The nurse observes early decelerations in the fetal heart rate. Which of the following actions should the nurse take?
- A. Continue to monitor the fetal heart rate
- B. Reposition the client
- C. Administer oxygen via face mask
- D. Increase the rate of the IV fluids
Correct answer: A
Rationale: Early decelerations are a benign finding that typically indicate fetal head compression, a normal response to uterine contractions. They do not require intervention as they are not associated with fetal compromise. The appropriate action for the nurse in this scenario is to continue to monitor the fetal heart rate. Repositioning the client, administering oxygen, or increasing IV fluids are not indicated responses to early decelerations and could be unnecessary or potentially harmful.
2. When does dehydration begin to occur?
- A. the body reduces fluid output to zero.
- B. the body increases the release of ANH.
- C. the salivary secretions decrease.
- D. the salivary secretions increase.
Correct answer: C
Rationale: Dehydration leads to a decrease in the body's fluid levels, causing the salivary glands to produce less saliva, resulting in a dry mouth. Therefore, when dehydration begins to occur, salivary secretions decrease. Choice A is incorrect because the body does not reduce fluid output to zero during dehydration; it tries to conserve fluids. Choice B is incorrect as dehydration does not directly increase the release of ANH (Atrial Natriuretic Hormone). Choice D is incorrect because salivary secretions do not increase but decrease during dehydration.
3. A nurse is planning care for a client with thrombocytopenia. Which of the following actions should the nurse include?
- A. Encourage the client to floss daily.
- B. Remove fresh flowers from the client's room.
- C. Provide the client with a stool softener.
- D. Avoid serving raw vegetables.
Correct answer: C
Rationale: The correct answer is C: Provide the client with a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Providing the client with a stool softener is essential to prevent straining during bowel movements, which could result in bleeding for clients with thrombocytopenia. Encouraging the client to floss daily (choice A) is unrelated to the management of thrombocytopenia. Removing fresh flowers (choice B) is more relevant for clients with a compromised immune system. Avoiding serving raw vegetables (choice D) is important for clients with compromised immune systems to prevent foodborne illnesses, but it is not directly related to thrombocytopenia.
4. A nurse is assessing a newborn who is 1-day old and receiving phototherapy for jaundice. Which action should the nurse take?
- A. Feed the infant glucose water every 2 hours.
- B. Ensure the newborn wears a diaper.
- C. Keep the infant's head covered with a cap.
- D. Apply lotion to the newborn every 4 hours.
Correct answer: C
Rationale: The correct action for the nurse to take is to keep the infant's head covered with a cap. This helps regulate the newborn's body temperature during phototherapy. Option A, feeding the infant glucose water every 2 hours, is incorrect because it is not a standard intervention for newborns receiving phototherapy. Option B, ensuring the newborn wears a diaper, may be necessary for hygiene but is not directly related to phototherapy. Option D, applying lotion to the newborn every 4 hours, is unnecessary and not indicated for managing jaundice or phototherapy.
5. A nurse is reviewing the laboratory results for a client who has Cushing's disease. The nurse should expect the client to have an increase in which of the following laboratory values?
- A. Serum glucose level.
- B. Serum calcium level.
- C. Lymphocyte count.
- D. Serum potassium level.
Correct answer: A
Rationale: The correct answer is A: Serum glucose level. In Cushing's disease, elevated cortisol levels lead to increased gluconeogenesis, insulin resistance, and breakdown of proteins and fats, resulting in elevated blood glucose levels. This is known as hyperglycemia. The other options, including serum calcium level (choice B), lymphocyte count (choice C), and serum potassium level (choice D), are not typically affected by Cushing's disease. Therefore, they are incorrect choices.
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