ATI LPN
PN ATI Capstone Maternal Newborn
1. A healthcare provider is assessing a newborn who is 48 hours old and is experiencing opioid withdrawals. Which of the following findings should the healthcare provider expect?
- A. Hypotonia
- B. Moderate tremors of the extremities
- C. Axillary temperature 36.1°C (96.9°F)
- D. Excessive crying
Correct answer: B
Rationale: The correct answer is B: Moderate tremors of the extremities. In newborns experiencing opioid withdrawals, moderate tremors of the extremities are a common sign. Other signs of opioid withdrawal in newborns may include irritability, feeding difficulties, and gastrointestinal disturbances. Choice A, hypotonia, is not typically associated with opioid withdrawal in newborns. Choice C, an axillary temperature of 36.1°C (96.9°F), falls within the normal range for newborns and is not specifically indicative of opioid withdrawal. Choice D, excessive crying, is not a typical sign of opioid withdrawal in newborns.
2. The nurse is assisting in the care of a client with a history of angina pectoris who is receiving nitroglycerin patches. Which instruction should the nurse reinforce with the client?
- A. Apply the patch to a different site each time.
- B. Remove the patch at night to prevent tolerance.
- C. Use more than one patch if chest pain occurs.
- D. Shower with caution while wearing the patch.
Correct answer: B
Rationale: Removing the nitroglycerin patch at night is crucial to prevent the development of tolerance. Tolerance can occur when the body becomes accustomed to a constant level of the medication, reducing its effectiveness. By removing the patch at night, the client experiences a drug-free period, which helps prevent tolerance and maintains the effectiveness of the nitroglycerin for angina relief. Choices A, C, and D are incorrect because applying the patch to a different site each time helps prevent skin irritation, using more than one patch is not recommended unless instructed by the healthcare provider, and showering with caution is important to prevent dislodging the patch, but it is not the most critical instruction to prevent tolerance development.
3. The healthcare provider is caring for a client who has just undergone a thyroidectomy. Which assessment finding requires immediate intervention?
- A. Hoarse voice.
- B. Difficulty swallowing.
- C. Numbness and tingling around the mouth.
- D. Sore throat.
Correct answer: C
Rationale: Numbness and tingling around the mouth can indicate hypocalcemia, a potential complication after thyroidectomy. Hypocalcemia can occur due to inadvertent injury or removal of the parathyroid glands during the thyroidectomy, leading to decreased calcium levels. As a result, the client may experience symptoms such as numbness, tingling, muscle cramps, or spasms. Prompt intervention is necessary to prevent severe complications like tetany or seizures. Therefore, the healthcare provider should address numbness and tingling around the mouth immediately to prevent further deterioration of calcium levels and potential serious outcomes. Choices A, B, and D are not typically associated with immediate post-thyroidectomy complications and can be addressed after ensuring the client's calcium levels are stable.
4. A food choice equivalent to one serving from the Grains group of MyPlate is:
- A. one slice of bread
- B. 2 cups of rice
- C. 3 cups of spaghetti
- D. 4 oz of ready-to-eat cereal
Correct answer: A
Rationale: One slice of bread is a standard serving from the Grains group in MyPlate. This choice aligns with the recommended portion size for grains. Choices B, C, and D are excessive portions that do not represent a single serving according to MyPlate guidelines. 2 cups of rice, 3 cups of spaghetti, and 4 oz of ready-to-eat cereal exceed the standard serving size for grains and would provide more than one serving from this food group.
5. An example of government nutrition policy is:
- A. MyPlate Food Guidance System.
- B. Dietary Guidelines for Americans 2010.
- C. Healthy People 2020.
- D. Dietary Reference Intakes (DRIs).
Correct answer: C
Rationale: The correct answer is C: Healthy People 2020. Healthy People 2020 is a government initiative that sets goals for improving the health of Americans, including specific nutritional objectives. Choices A, B, and D are not examples of government nutrition policies. MyPlate Food Guidance System is a visual tool to help individuals make healthy food choices, Dietary Guidelines for Americans 2010 provide evidence-based advice for Americans two years and older, and Dietary Reference Intakes (DRIs) are a set of nutrient reference values.
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