ATI LPN
PN ATI Capstone Maternal Newborn
1. A nurse is assessing a newborn and notes that the infant has yellow-tinged skin. Which of the following is the priority nursing action?
- A. Assess the infant's bilirubin levels
- B. Initiate phototherapy
- C. Monitor the infant's temperature
- D. Encourage breastfeeding
Correct answer: A
Rationale: Yellow-tinged skin (jaundice) in a newborn can indicate hyperbilirubinemia. The priority action is to assess the infant's bilirubin levels to determine the severity of the jaundice and the need for further interventions, such as phototherapy. Initiating phototherapy (choice B) is premature without knowing the actual bilirubin levels. Monitoring the infant's temperature (choice C) is important but not the priority in this situation. Encouraging breastfeeding (choice D) is beneficial but not the priority when dealing with jaundice in a newborn.
2. A nurse is preparing to administer a dose of iron supplement. Which of the following should the nurse do?
- A. Give it with milk
- B. Administer it on an empty stomach
- C. Check blood pressure
- D. Monitor for allergic reactions
Correct answer: B
Rationale: The correct answer is B: Administer it on an empty stomach. Iron supplements are best absorbed on an empty stomach to enhance their absorption. It is important to avoid giving them with milk or dairy products as these can inhibit iron absorption. Checking blood pressure and monitoring for allergic reactions are not directly related to the administration of iron supplements and are not the primary considerations in this case.
3. A nurse in a provider's office is assessing a client who reports a decrease in the effectiveness of their arthritis medication. Which of the following client information should the nurse identify as a contributing factor?
- A. The client has a history of recurring bowel inflammation.
- B. The client has recently increased their exercise regimen.
- C. The client is taking herbal supplements.
- D. The client is experiencing increased stress.
Correct answer: A
Rationale: The correct answer is A. Recurring bowel inflammation can decrease gastrointestinal motility, affecting the absorption of oral medications. This can lead to decreased effectiveness of the arthritis medication. Choice B is incorrect because increasing exercise would not typically impact the absorption of arthritis medication. Choice C is incorrect as herbal supplements may not directly affect the absorption of conventional arthritis medication. Choice D is also incorrect as stress, while it can impact overall health, is less likely to directly affect the effectiveness of arthritis medication compared to gastrointestinal issues.
4. A nurse is preparing to administer a dose of warfarin. Which of the following should the nurse do?
- A. Check INR levels
- B. Administer it with food
- C. Monitor blood glucose
- D. Assess liver function
Correct answer: A
Rationale: The correct answer is to check INR levels. Before administering warfarin, it is crucial to check the INR levels to ensure they are within the therapeutic range. This helps to prevent complications such as bleeding or clotting. Choice B, administering it with food, is incorrect as warfarin should typically be taken on an empty stomach. Choice C, monitoring blood glucose, is unrelated to the administration of warfarin. Choice D, assessing liver function, is important but not the immediate action required before administering warfarin.
5. When caring for a client prescribed azithromycin, what should the nurse monitor?
- A. Liver function
- B. Signs of diarrhea
- C. Blood glucose levels
- D. Serum electrolytes
Correct answer: B
Rationale: The correct answer is to monitor signs of diarrhea when a client is prescribed azithromycin. Azithromycin is known to cause gastrointestinal side effects, particularly diarrhea. Monitoring for diarrhea is crucial to assess the client's response to the medication and to prevent complications such as dehydration. Monitoring liver function (choice A), blood glucose levels (choice C), and serum electrolytes (choice D) are not typically indicated specifically for clients prescribed azithromycin unless there are other specific reasons or conditions that warrant such monitoring.
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