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?
- A. Preeclampsia
- B. Gestational diabetes
- C. Anemia
- D. Placenta previa
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 is caring for a client with a new prescription for clindamycin. Which of the following should the nurse monitor?
- A. Liver function
- B. Serum potassium
- C. Signs of superinfection
- D. Blood glucose
Correct answer: C
Rationale: The correct answer is C: Signs of superinfection. Clindamycin can lead to antibiotic-associated colitis and other superinfections, making it crucial for the nurse to monitor the client for signs of superinfection. Monitoring liver function (choice A) is not typically associated with clindamycin use. Serum potassium levels (choice B) and blood glucose (choice D) are also not directly affected by clindamycin, so they are not the priority for monitoring in this case.
3. A nurse is preparing to administer a dose of ampicillin. Which of the following actions should the nurse take?
- A. Administer it with food
- B. Check for penicillin allergy
- C. Monitor liver function
- D. Administer it intramuscularly
Correct answer: B
Rationale: The correct answer is to 'Check for penicillin allergy.' Before administering ampicillin, it is crucial to assess the patient for any history of penicillin allergy. This is essential to prevent an adverse allergic reaction, as ampicillin belongs to the penicillin class of antibiotics. Administering ampicillin with food (Choice A) is not a standard requirement and does not impact its effectiveness. Monitoring liver function (Choice C) is not directly related to the immediate pre-administration assessment for ampicillin. Administering ampicillin intramuscularly (Choice D) is not typically the route of administration for this antibiotic, as it is usually given intravenously or orally.
4. A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following statements by the client indicates a need for further teaching?
- A. I will take ibuprofen for headaches.
- B. I will use an electric razor to shave.
- C. I will avoid eating large amounts of leafy green vegetables.
- D. I will have my blood levels checked regularly.
Correct answer: A
Rationale: The correct answer is A. Ibuprofen can increase the risk of bleeding when taken with warfarin, as both medications affect clotting. The client should use alternative pain relievers like acetaminophen. Choice B is correct as using an electric razor is a safe choice to prevent cuts that could lead to bleeding. Choice C is correct as warfarin interacts with vitamin K found in leafy green vegetables. Choice D is correct as regular blood level checks are necessary to monitor the effects and adjust the warfarin dosage if needed.
5. A nurse is preparing to insert an indwelling urinary catheter into a female client. Which of the following actions should the nurse take?
- A. Inflate the balloon with 10 mL of sterile water prior to insertion
- B. Cleanse the client’s labia and meatus using a front-to-back motion
- C. Ask the client to bear down while inserting the catheter
- D. Inflate the catheter balloon after urine begins to flow
Correct answer: D
Rationale: The correct action for the nurse to take when inserting an indwelling urinary catheter into a female client is to inflate the catheter balloon after urine begins to flow. Inflating the balloon before urine starts flowing can lead to incorrect placement in the urethra, causing trauma. Cleansing the labia and meatus should be done before the insertion, but the crucial step of inflating the balloon should occur after the catheter is correctly placed. Asking the client to bear down is not necessary during catheter insertion.
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