a nurse is assessing a pregnant client at 32 weeks gestation and notes that the client has gained 5 pounds in one week which of the following conditio
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Nursing Elites

ATI LPN

PN ATI Capstone Maternal Newborn

1. A nurse is assessing a pregnant client at 32 weeks gestation and notes that the client has gained 5 pounds in one week. Which of the following conditions should the nurse suspect?

Correct answer: A

Rationale: The correct answer is A: Preeclampsia. Rapid weight gain, especially in the third trimester, can be a sign of preeclampsia, a condition characterized by hypertension, edema, and proteinuria. This requires immediate medical attention. Choice B, Gestational diabetes, is incorrect because rapid weight gain is not a typical symptom of gestational diabetes. Choice C, Anemia, is incorrect as weight gain is not a common sign of anemia in pregnancy. Choice D, Placenta previa, is also incorrect because weight gain is not a typical symptom of this condition, which involves the placenta partially or completely covering the cervix.

2. A nurse has been caring for a female client who has bruises on her arms that she explains are a result of physical abuse by her husband. The client states, “I don’t know how much longer I can take this, but I’m afraid he’ll really hurt me if I leave.” Which of the following is an appropriate nursing intervention?

Correct answer: D

Rationale: Assisting the client in reporting the abuse is a critical step in ensuring her safety and initiating legal action to protect her from further harm. Option A is inappropriate as it may escalate the situation and put the client at further risk. Option B focuses on the client recognizing signs of abuse, which is not as urgent as reporting it to authorities. Option C places the responsibility on the client for triggering the abuse, which is victim-blaming and not helpful in this context.

3. A nurse is teaching a client about nonpharmacological pain management techniques. Which statement about hypnosis is appropriate?

Correct answer: A

Rationale: The correct answer is A: "Hypnosis promotes increased control of pain perception during labor." Hypnosis can be effectively utilized during labor to help individuals enhance their control over how they perceive pain. Choice B is incorrect because hypnosis does not primarily use therapeutic touch to reduce anxiety. Choice C is incorrect as hypnosis is not primarily focused on biofeedback as a relaxation technique. Choice D is incorrect because hypnosis does not provide direct instructions to minimize pain but rather helps individuals gain control over their pain perception.

4. Before administering blood products, which action should be taken?

Correct answer: A

Rationale: Before administering blood products, assessing the patient’s temperature is crucial. This action provides baseline data to detect any febrile reactions during or after the transfusion. Fever may indicate a transfusion reaction, so continuous monitoring of vital signs is essential throughout the procedure. Documenting the patient’s response (choice B) is important but comes after assessing the temperature. Priming IV tubing with 0.45% sodium chloride (choice C) is not directly related to the initial action required before administering blood products. Administering epinephrine (choice D) is not indicated unless there is a severe allergic reaction, which is not the standard initial step before blood product administration.

5. A healthcare provider is preparing to administer a vaccine to a child. Which of the following should the provider verify?

Correct answer: B

Rationale: The healthcare provider should verify the child's previous vaccination history to ensure they are up to date with immunizations. This is important to prevent unnecessary or duplicate vaccinations and ensure the child is adequately protected against vaccine-preventable diseases. Checking for allergies to eggs is relevant for certain vaccines like the influenza vaccine but is not the top priority in this scenario. Family medical history and growth charts are not directly related to the administration of vaccines and are not as crucial as confirming the child's vaccination status.

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