ATI LPN
PN ATI Capstone Maternal Newborn
1. A nurse is assessing a newborn who was born vaginally with vacuum extractor assistance. The nurse notes swelling over the newborn's head that crosses the suture line. The nurse should identify the swelling as which of the following findings?
- A. Nevus simplex
- B. Caput succedaneum
- C. Cephalohematoma
- D. Erythema toxicum
Correct answer: B
Rationale: Caput succedaneum is the correct answer. It is the swelling of the soft tissues of the head that crosses suture lines, often resulting from pressure during delivery, especially with vacuum extraction. Nevus simplex (Choice A) is a pink or red birthmark that is flat and usually fades on its own. Cephalohematoma (Choice C) is a collection of blood between a baby's skull and the periosteum, often caused by birth trauma. Erythema toxicum (Choice D) is a common rash in newborns that is benign and typically resolves on its own. In this case, the description of swelling over the newborn's head crossing the suture line is characteristic of caput succedaneum, which is a common finding in newborns after vaginal delivery.
2. A nurse is assessing a client who has been taking phenytoin for epilepsy. Which of the following findings should the nurse report to the provider?
- A. Weight loss
- B. Gingival hyperplasia
- C. Increased thirst
- D. Frequent urination
Correct answer: B
Rationale: The correct answer is B: Gingival hyperplasia. Phenytoin is known to cause gingival hyperplasia, an overgrowth of gum tissue, which can lead to oral health issues and requires dental care. Choices A, C, and D are not directly associated with phenytoin use. Weight loss, increased thirst, and frequent urination are not typically reported findings related to phenytoin and should not be prioritized over gingival hyperplasia when assessing a client taking this medication.
3. The Acceptable Macronutrient Distribution Range for fat recommends that the percentage of total kcalories from fat should fall between:
- A. 10% and 20%.
- B. 20% and 25%.
- C. 20% and 35%.
- D. 30% and 45%.
Correct answer: C
Rationale: The Acceptable Macronutrient Distribution Range (AMDR) for fat suggests that 20% to 35% of total kcalories should come from fat. This range is recommended to maintain good health. Choices A, B, and D are incorrect because they do not fall within the specified range. A lower percentage (10-20%) may not provide enough essential fatty acids, while a higher percentage (30-45%) may increase the risk of health issues associated with excessive fat consumption.
4. A healthcare professional is preparing to transfer a client who has had a stroke and is at risk for falling to a rehabilitation facility. Which of the following information should the healthcare professional include in the transfer report?
- A. The client's urination habits.
- B. The client's financial information.
- C. The client's social history.
- D. The client's current level of mobility.
Correct answer: D
Rationale: The client's current level of mobility is essential to be included in the transfer report for the rehabilitation facility to develop an appropriate care plan. Understanding the client's mobility status helps in determining the level of assistance and interventions needed to prevent falls and promote safe rehabilitation. Choices A, B, and C are not directly related to the client's immediate care needs during the transfer to the rehabilitation facility, making them less relevant for the transfer report.
5. A client is on a mechanical ventilator. Which client response indicates that the neuromuscular blocker tubocurarine chloride (Tubarine) is effective?
- A. The client's extremities are paralyzed.
- B. The peripheral nerve stimulator causes twitching.
- C. The client clenches fist upon command.
- D. The client's Glasgow Coma Scale score is 14.
Correct answer: A
Rationale: The correct answer is A. Tubocurarine chloride is a neuromuscular blocker that works by causing paralysis of skeletal muscles. Therefore, if the client's extremities are paralyzed, it indicates that the medication is effective in achieving the desired muscle relaxation necessary for mechanical ventilation. Choices B and C are incorrect as they suggest muscle activity, which would not be expected with the administration of a neuromuscular blocker. Choice D is unrelated to the effectiveness of tubocurarine chloride.
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