ATI LPN
Maternal Newborn ATI Proctored Exam
1. A client at 40 weeks of gestation is experiencing contractions every 3 to 5 minutes, becoming stronger. A vaginal exam by the registered nurse reveals the client's cervix is 3 cm dilated, 80% effaced, and -1 station. The client requests pain medication. Which of the following actions should the nurse prepare to take? (Select all that apply)
- A. Provide ice chips.
- B. Insert an indwelling urinary catheter.
- C. Administer opioid analgesic medication.
- D. Provide ice chips.
Correct answer: C
Rationale: During labor, effective pain management is crucial. The nurse should assist the client with patterned breathing techniques to help manage pain and administer opioid analgesic medication as ordered. Providing ice chips is a comfort measure but does not directly address pain relief. Inserting a urinary catheter is not typically indicated at this stage of labor unless there are specific medical indications, such as the need to closely monitor urine output. Therefore, the correct action for the nurse to prepare to take in this scenario is to administer opioid analgesic medication.
2. In which of the following situations would the use of physical restraints most likely be justified?
- A. Mr. Y is agitated and aggressive while experiencing severe alcohol withdrawal and is not responding to chemical sedation.
- B. Mrs. U, diagnosed with dementia, was found wandering outside the hospital, and nurses have been unable to redirect her to stay on the unit.
- C. Mr. I is delirious during the acute stage of his urinary tract infection and is ringing the call bell nearly continuously.
- D. Mrs. T is frequently entering other patients' rooms and attempting to crawl into others' beds.
Correct answer: A
Rationale: Answer A is the correct choice because it describes a situation where the client poses a risk due to agitation and aggression during severe alcohol withdrawal, and chemical sedation has not been effective. In such cases, physical restraints may be justified as a last resort to ensure the safety of the client and others. Choices B, C, and D present scenarios where alternative strategies like redirection, addressing delirium, or implementing behavioral interventions should be attempted before considering physical restraints.
3. A nurse is caring for a client who has a prescription for chlorothiazide to treat hypertension. The nurse should plan to monitor the client for which of the following adverse effects?
- A. Thrombophlebitis
- B. Hyperactive reflexes
- C. Muscle weakness
- D. Hypoglycemia
Correct answer: C
Rationale: The correct answer is C: Muscle weakness. Chlorothiazide, a thiazide diuretic, can lead to hypokalemia, which can cause muscle weakness. Thrombophlebitis (choice A) is not typically associated with chlorothiazide use. Hyperactive reflexes (choice B) and hypoglycemia (choice D) are also not commonly linked to this medication. Therefore, monitoring for muscle weakness is crucial when a client is prescribed chlorothiazide.
4. What is the primary benefit of administering Vitamin A to children?
- A. To improve bone health
- B. To boost the immune system
- C. To enhance cognitive development
- D. To prevent anemia
Correct answer: B
Rationale: The primary benefit of administering Vitamin A to children is to boost the immune system. Vitamin A supplementation is crucial for maintaining a strong immune system and preventing complications such as blindness in children.
5. A nurse is caring for a client prescribed metoprolol. Which of the following should the nurse monitor for as an adverse effect of this medication?
- A. Bradycardia
- B. Hypotension
- C. Tachycardia
- D. Hyperglycemia
Correct answer: B
Rationale: The correct answer is B: Hypotension. Metoprolol, a beta-blocker, can lead to a decrease in blood pressure, resulting in hypotension. Monitoring blood pressure regularly is essential to detect and manage this adverse effect. Choices A, C, and D are incorrect because metoprolol typically does not cause bradycardia, tachycardia, or hyperglycemia as its primary adverse effects.
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