ATI LPN
PN ATI Capstone Maternal Newborn
1. A client gave birth 4 hours ago and is experiencing excessive vaginal bleeding. Which of the following actions should the nurse plan to take first?
- A. Elevate the client's legs to a 30° angle
- B. Insert an indwelling urinary catheter
- C. Massage the client's fundus
- D. Initiate an infusion of oxytocin
Correct answer: C
Rationale: The correct answer is to massage the client's fundus first. Uterine atony is a common cause of postpartum hemorrhage, and massaging the fundus can help stimulate uterine contractions, which will assist in reducing bleeding. Elevating the client's legs to a 30° angle (Choice A) is not the priority in this situation as fundal massage takes precedence. Inserting an indwelling urinary catheter (Choice B) may be necessary but should not take precedence over managing the postpartum hemorrhage. Initiating an infusion of oxytocin (Choice D) is a valid intervention to address uterine atony, but massaging the fundus should come first to promote immediate contraction and control bleeding.
2. A mother of a 6-year-old actively playing child, diagnosed with type 1 diabetes mellitus a year ago, calls a clinic nurse and reports that the child has been sick. She checked the child's urine, which was positive for ketones. What should the nurse instruct the mother to do?
- A. Administer an additional dose of regular insulin
- B. Come to the clinic immediately
- C. Encourage the child to drink liquids
- D. Hold the next dose of insulin
Correct answer: C
Rationale: Encouraging the child to drink liquids is essential in managing ketones in urine. Increased fluid intake can help prevent dehydration and aid in flushing out ketones, which is crucial in managing diabetic ketoacidosis, a serious complication of uncontrolled diabetes.
3. A nurse is assessing a client who is taking hydrocodone. Which of the following findings should the nurse report to the provider?
- A. Constipation
- B. Sedation
- C. Dry mouth
- D. Respiratory depression
Correct answer: D
Rationale: The correct answer is D: Respiratory depression. Hydrocodone is an opioid medication that can cause respiratory depression, a serious side effect that should be reported immediately to the healthcare provider. Constipation, sedation, and dry mouth are common side effects of hydrocodone but are not as concerning as respiratory depression. Constipation can be managed with lifestyle modifications and medications, sedation may improve with time or dosage adjustments, and dry mouth is a common and usually benign side effect.
4. A client has a new diagnosis of hyperthyroidism and is being taught about dietary management. Which of the following statements should the nurse include in the teaching?
- A. You should increase your intake of iodine-rich foods.
- B. You should avoid foods that contain iodine.
- C. You should increase your intake of dairy products.
- D. You should avoid foods that contain gluten.
Correct answer: B
Rationale: The correct answer is B. In hyperthyroidism, it is advisable to avoid foods that contain iodine to help manage the condition and prevent complications. Excessive iodine intake can exacerbate hyperthyroidism symptoms by stimulating the thyroid gland. Therefore, the nurse should include information about avoiding iodine-rich foods in the client's dietary management teaching. Choices A, C, and D are incorrect because increasing intake of iodine-rich foods can worsen hyperthyroidism symptoms, increasing dairy products is not specific to managing hyperthyroidism, and avoiding gluten is more relevant for conditions like celiac disease, not hyperthyroidism.
5. What is a key objective of the Global Immunization Vision and Strategy (GIVS)?
- A. Eliminating non-communicable diseases
- B. Improving access to high-quality immunization services
- C. Reducing the cost of healthcare
- D. Increasing the number of healthcare professionals
Correct answer: B
Rationale: The Global Immunization Vision and Strategy (GIVS) aims to improve access to high-quality immunization services globally. This objective focuses on enhancing the availability and quality of immunization services to ensure that more individuals have access to vaccines to prevent diseases.
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