ATI RN
ATI Capstone Maternal Newborn Assessment Quizlet
1. A nurse is assessing a newborn who was delivered 24 hours ago. Which of the following findings should the nurse report to the provider?
- A. Caput succedaneum
- B. Jaundice
- C. Acrocyanosis
- D. Overlapping cranial sutures
Correct answer: B
Rationale: Jaundice occurring within the first 24 hours of life is a sign of pathological jaundice and should be reported to the provider. Caput succedaneum, acrocyanosis, and overlapping cranial sutures are common findings in newborns and do not necessarily require immediate reporting unless they are severe or indicate other underlying issues.
2. What is the most likely complication for a client receiving TPN who suddenly develops tremors, dizziness, and diaphoresis?
- A. Fluid volume overload
- B. Sepsis
- C. Hyperglycemia
- D. Hypoglycemia
Correct answer: D
Rationale: The correct answer is D, Hypoglycemia. When a client receiving TPN suddenly develops tremors, dizziness, and diaphoresis, it is indicative of hypoglycemia. TPN provides a high concentration of glucose, and if it is abruptly stopped or the infusion rate is reduced, it can lead to hypoglycemia. Choices A, B, and C are incorrect as they do not directly correlate with the symptoms described in the scenario. Fluid volume overload typically presents with edema and hypertension, sepsis with fever and increased heart rate, and hyperglycemia with polyuria, polydipsia, and blurred vision.
3. In assessing the client's chest, which position best shows chest expansion as well as its movements?
- A. Sitting
- B. Prone
- C. Sidelying
- D. Supine
Correct answer: A
Rationale: The correct answer is A: Sitting. When the client is seated, their chest is in an optimal position for observing the full range of chest expansion during breathing. This position allows for easy visualization of chest movements and expansion as the client breathes in and out, providing a comprehensive assessment of respiratory function. Choice B, Prone, is incorrect as lying face down would not provide a clear view of chest expansion. Choice C, Sidelying, is also incorrect as this position may limit the visibility of chest movements. Choice D, Supine, is not the best position for assessing chest expansion as it may not offer a clear observation of chest movements during breathing.
4. A nurse is caring for a child who is allergic to penicillin. The nurse should verify which of the following prescriptions with the provider?
- A. Amphotericin B
- B. Amoxicillin-clavulanate
- C. Erythromycin
- D. Gentamicin
Correct answer: B
Rationale: Amoxicillin-clavulanate is related to penicillin, and a cross-sensitivity could occur, so the provider should be consulted.
5. A client with schizophrenia is experiencing auditory hallucinations. Which nursing intervention should the nurse implement to address this symptom?
- A. Encourage the client to express feelings about the hallucinations.
- B. Distract the client from the hallucinations.
- C. Provide reality-based feedback about the hallucinations.
- D. Encourage the client to ignore the hallucinations.
Correct answer: C
Rationale: The correct intervention for a client experiencing auditory hallucinations in schizophrenia is to provide reality-based feedback about the hallucinations. By providing reality-based feedback, the nurse helps the client differentiate between what is real and what is not, which can help decrease the distress and impact of the hallucinations on the client's perception of reality. Encouraging the client to express feelings (Choice A) may not directly address the hallucinations. Distracting the client (Choice B) may temporarily alleviate the symptoms but does not help the client differentiate reality from hallucinations. Encouraging the client to ignore the hallucinations (Choice D) may not be effective as the client may struggle to do so without appropriate guidance.
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