ATI LPN
PN ATI Capstone Maternal Newborn
1. A nurse is assessing a newborn who is 10 hours old. Which of the following findings should the nurse report to the provider?
- A. Axillary temperature 36.5°C (97.7°F)
- B. Nasal flaring
- C. Heart rate 158/min
- D. One void since birth
Correct answer: B
Rationale: Nasal flaring can indicate respiratory distress in a newborn, which is a critical finding requiring immediate attention. This may suggest an issue with breathing or lung function. Reporting nasal flaring promptly allows the provider to assess and intervene to ensure the newborn's respiratory status is stable. Choices A, C, and D are within normal parameters for a 10-hour-old newborn and do not indicate an immediate concern. An axillary temperature of 36.5°C (97.7°F) is within the normal range for a newborn. A heart rate of 158/min is typical for a newborn, and one void since birth is an expected finding at this early stage.
2. A client with a cystocele is encouraged to exercise to strengthen pelvic floor muscles and prevent pelvic organ prolapse. What exercise will the client need to perform?
- A. Kegel exercises
- B. Isometric exercises
- C. Circumduction exercises
- D. Uterine extension exercises
Correct answer: A
Rationale: Corrected Rationale: The client with a cystocele should perform Kegel exercises to strengthen the pelvic floor muscles, reducing the risk of pelvic organ prolapse and stress urinary incontinence. Kegel exercises specifically target the muscles that support the pelvic organs. Isometric exercises focus on static muscle contractions and may not be as effective as Kegel exercises for strengthening the pelvic floor. Circumduction exercises involve circular movements at joints and are not specific to pelvic floor muscle strengthening. Uterine extension exercises do not directly target the pelvic floor muscles and are not indicated for cystocele management.
3. A nurse is preparing to administer an enteral tube feeding through an NG tube at 250 mL over 4 hr. The nurse should set the pump to deliver how many mL/hr?
- A. 60 mL/hr
- B. 62 mL/hr
- C. 63 mL/hr
- D. 65 mL/hr
Correct answer: C
Rationale: Calculation: 250 mL / 4 hours = 62.5 mL/hr, which should be rounded up to 63 mL/hr. This ensures the correct rate is set for continuous feeding. Choice A (60 mL/hr) is incorrect as it does not reflect the accurate calculation. Choice B (62 mL/hr) is close but does not round up to the nearest whole number as required. Choice D (65 mL/hr) is higher than the correct calculation and would deliver the feeding solution at a faster rate than prescribed.
4. A client is being taught about the use of levothyroxine. Which of the following should be included?
- A. It should be taken on an empty stomach
- B. Monitor for signs of hyperthyroidism
- C. It is a pain reliever
- D. It should be taken in the morning
Correct answer: B
Rationale: When educating a client about levothyroxine, it is important to emphasize the need to monitor for signs of hyperthyroidism. Levothyroxine should be taken on an empty stomach, preferably in the morning, to maximize its absorption. Choice A is incorrect as it should not be taken with food. Choice C is incorrect as levothyroxine is not a pain reliever. Choice D is incorrect as levothyroxine is usually taken in the morning.
5. A client has been prescribed nitroglycerin for chest pain. Which of the following should the nurse include in the teaching?
- A. Take one tablet every hour for chest pain.
- B. Store nitroglycerin tablets in a cool, dark place.
- C. Take nitroglycerin with food to reduce stomach upset.
- D. Take nitroglycerin with an antacid to prevent heartburn.
Correct answer: B
Rationale: The correct answer is B. Nitroglycerin tablets should be stored in a cool, dark place to maintain their potency. Storing them correctly ensures that they remain effective when needed. Choices A, C, and D are incorrect. Taking one tablet every hour is not the correct dosing regimen for nitroglycerin. Nitroglycerin is usually taken as needed at the onset of chest pain, with specific instructions from the healthcare provider. Taking nitroglycerin with food or antacids is not necessary, as it is usually placed under the tongue for rapid absorption.
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