a nurse is caring for a client in active labor who is receiving oxytocin the nurse notes that the client is experiencing contractions every 1 minute l
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Nursing Elites

ATI LPN

PN ATI Capstone Maternal Newborn

1. A nurse is caring for a client in active labor who is receiving oxytocin. The nurse notes that the client is experiencing contractions every 1 minute lasting 90 seconds. Which of the following actions should the nurse take?

Correct answer: A

Rationale: The correct action the nurse should take in this situation is to stop the oxytocin infusion. Contractions occurring every 1 minute lasting 90 seconds indicate uterine hyperstimulation, which can lead to fetal distress by compromising oxygen supply. Stopping the oxytocin infusion will help reduce the frequency and intensity of contractions, allowing for better fetal oxygenation. Administering oxygen (Choice B) may be necessary if there are signs of fetal distress, but stopping the oxytocin is the priority. Increasing IV fluid rate (Choice C) is not the appropriate action in response to hyperstimulation. While preparing for delivery (Choice D) may eventually be necessary, the immediate action should be to address the hyperstimulation by stopping the oxytocin infusion.

2. A nurse is providing teaching to a client who has chronic kidney disease. Which of the following client statements indicates an understanding of the teaching?

Correct answer: A

Rationale: The correct answer is A. Clients with chronic kidney disease should limit their intake of phosphorus because high phosphorus levels can lead to bone disease and cardiovascular problems. Increasing foods high in potassium (choice B) is not recommended as it can be harmful to individuals with kidney disease. Decreasing intake of foods high in iron (choice C) is not specifically indicated for chronic kidney disease. Increasing calcium supplements (choice D) may not be necessary and can potentially lead to hypercalcemia in individuals with kidney disease.

3. A client just received the first dose of lisinopril. Which of the following is an appropriate nursing intervention?

Correct answer: C

Rationale: The correct answer is to provide standby assistance when getting out of bed. Lisinopril can cause first-dose hypotension, leading to dizziness and increasing the risk of falls. Standby assistance helps ensure the client's safety when mobilizing. Placing the client on cardiac monitoring (choice A) is not necessary unless there are specific indications for cardiac monitoring. Monitoring oxygen saturation (choice B) is not directly related to the side effects of lisinopril. Encouraging foods high in potassium (choice D) is not the most immediate or appropriate intervention following the administration of lisinopril.

4. A client has a stool culture positive for C. difficile. What action should the nurse take?

Correct answer: D

Rationale: When caring for a client with a C. difficile infection, it is essential to isolate them in a private room to prevent the spread of spores through contact with surfaces. Placing the client in a negative pressure room (Choice A) is not necessary for C. difficile. Using alcohol-based hand rub (Choice B) and wearing a face shield (Choice C) are important infection control measures but are not specific to the isolation requirements for C. difficile.

5. A nurse is caring for a client with Alzheimer's disease. Which action should the nurse include in the care plan to support the client’s cognitive function?

Correct answer: A

Rationale: Placing a daily calendar in the kitchen is beneficial for clients with Alzheimer's disease as it helps in orienting them to time and enhances cognitive function. This visual aid can assist in keeping track of days and activities. Choice B, replacing buttoned clothing with zippered items, is more related to promoting independence in dressing rather than directly supporting cognitive function. Choice C, replacing carpet with hardwood floors, focuses on safety and mobility rather than cognitive function. Choice D, creating variation in the daily routine, may be helpful for engagement and stimulation but does not directly address cognitive function as effectively as using a daily calendar.

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