ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B
1. While caring for a client receiving oxytocin for labor augmentation, the nurse notes contractions occurring every 45 seconds and lasting 90 seconds. What should the nurse do?
- A. Discontinue the oxytocin infusion
- B. Increase the oxytocin infusion
- C. Apply an internal fetal monitor
- D. Administer an analgesic
Correct answer: A
Rationale: The correct action for the nurse to take in this situation is to discontinue the oxytocin infusion. The client is experiencing uterine hyperstimulation, which can lead to fetal distress and complications. By stopping the oxytocin, the nurse can help regulate contractions and prevent harm to the fetus. Increasing the oxytocin infusion would exacerbate the issue by further intensifying contractions. Applying an internal fetal monitor may be necessary for closer monitoring but is not the immediate action required. Administering an analgesic is not appropriate in this scenario as the primary concern is addressing the uterine hyperstimulation caused by oxytocin.
2. Which of the following characteristics would indicate true labor in a client?
- A. Contractions are irregular and painless
- B. Fetus moves to an anterior position
- C. Bloody show is not present
- D. Contractions are regular in frequency
Correct answer: D
Rationale: The correct answer is D. True labor is characterized by regular contractions that increase in intensity and frequency. These contractions lead to cervical dilation and effacement, signaling the onset of labor. Choice A is incorrect because true labor contractions are regular and painful, not irregular and painless. Choice B is irrelevant to determining true labor. Choice C is also unrelated as the presence or absence of a bloody show does not definitively indicate true labor.
3. A client has a new prescription for lisinopril. Which of the following findings should be reported to the provider by the nurse?
- A. Weight gain
- B. Dry cough
- C. Hypokalemia
- D. Increased appetite
Correct answer: B
Rationale: The correct answer is B - Dry cough. Lisinopril is known to cause a persistent dry cough as a common side effect. This adverse reaction can be bothersome to the client and may necessitate discontinuation of the medication. Weight gain, hypokalemia, and increased appetite are not typically associated with lisinopril and would not be as concerning as a dry cough when assessing for adverse effects.
4. A 3-year-old female presents with respiratory distress. She is conscious, crying, and clinging to her mother. She has mild intercostal retractions and an oxygen saturation of 93%. The MOST effective way of delivering oxygen to her involves:
- A. gently restraining her and assisting with ventilations.
- B. ventilations with a flow-restricted, oxygen-powered device.
- C. a non-rebreathing mask with the flow rate set at 6 to 8 L/min.
- D. asking the mother to hold an oxygen mask near her face.
Correct answer: C
Rationale: In a pediatric patient with respiratory distress, a non-rebreathing mask with a flow rate set at 6 to 8 L/min is the most effective way to deliver oxygen. This method ensures a high concentration of oxygen is delivered to the child, aiding in improving oxygen saturation levels. In this scenario, the mother can assist in holding the mask to maintain comfort and cooperation in the child while ensuring proper oxygen delivery.
5. A nurse is caring for a client who has a deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?
- A. Encourage the client to ambulate frequently.
- B. Apply warm, moist compresses to the affected leg.
- C. Massage the affected leg.
- D. Place the client in a supine position.
Correct answer: B
Rationale: The correct intervention for a client with deep vein thrombosis (DVT) is to apply warm, moist compresses to the affected leg. This helps alleviate pain and improve circulation in the affected area, aiding in the treatment of DVT. Encouraging the client to ambulate frequently (Choice A) is contraindicated as it can dislodge the clot and lead to complications. Massaging the affected leg (Choice C) is also contraindicated as it can dislodge the clot and potentially cause an embolism. Placing the client in a supine position (Choice D) is not specifically indicated for DVT treatment; elevation of the affected leg is preferred over placing the client completely supine.
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