ATI LPN
ATI Maternal Newborn
1. A newborn is noted to have secretions bubbling out of the nose and mouth after delivery. What is the nurse's priority action?
- A. Suction the nose with a bulb syringe.
- B. Suction the mouth with a bulb syringe.
- C. Use a suction catheter with low negative pressure.
- D. Turn the newborn on their side.
Correct answer: B
Rationale: The priority action for the nurse is to suction the mouth with a bulb syringe. Suctioning the mouth first is crucial to prevent aspiration and ensure the airway is clear, which takes precedence over suctioning the nose. This intervention helps maintain a patent airway and promotes adequate breathing in the newborn. Using a suction catheter with low negative pressure may not be appropriate as the newborn needs a gentle suction method like a bulb syringe. Turning the newborn on their side is important if there is a risk of aspiration, but clearing the mouth of secretions should be the priority to establish a clear airway.
2. A healthcare provider is providing education on the use of clozapine. Which of the following should be included?
- A. Monitor for agranulocytosis
- B. It is a first-line treatment
- C. It can cause significant weight loss
- D. It has no risk for metabolic syndrome
Correct answer: A
Rationale: Correct Answer: A nurse should include monitoring for agranulocytosis when educating a patient about clozapine. Clozapine is known to cause agranulocytosis, a potentially life-threatening decrease in white blood cells. This adverse effect requires close monitoring to detect it early. Choices B, C, and D are incorrect because clozapine is not a first-line treatment for most conditions, it is more commonly associated with weight gain rather than weight loss, and it is known to have a risk for metabolic syndrome.
3. Which of the following individuals should be considered as special targets for family planning?
- A. Individuals with two or more children
- B. Individuals with medical conditions such as anemia
- C. Individuals younger than 20 years or older than 35 years
- D. Individuals who have had a delivery within the past 15 months
Correct answer: D
Rationale: Individuals who have had a delivery within the past 15 months should be considered special targets for family planning because the ideal birth spacing is at least two years. By waiting two years (15 months post-delivery + 9 months of pregnancy), the individual can give their body enough time to recover and reduce potential health risks associated with closely spaced pregnancies.
4. 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.
5. What is the role of a nurse in managing a patient with acute kidney injury (AKI)?
- A. Monitor urine output and electrolyte levels
- B. Administer diuretics and restrict potassium
- C. Provide dietary education and monitor fluid intake
- D. Administer antibiotics and check for dehydration
Correct answer: A
Rationale: The correct answer is A: 'Monitor urine output and electrolyte levels.' In managing a patient with acute kidney injury (AKI), it is crucial for the nurse to monitor urine output and electrolyte levels to assess kidney function and the patient's fluid and electrolyte balance. This monitoring helps in early detection of any worsening kidney function or electrolyte imbalances. Choice B is incorrect because administering diuretics and restricting potassium may not be appropriate for all AKI patients and should be done under the direction of a healthcare provider. Choice C is also incorrect as providing dietary education and monitoring fluid intake are important but do not directly address the immediate management of AKI. Choice D is incorrect as administering antibiotics and checking for dehydration are not primary interventions for managing AKI; antibiotics are only given if there is an infection contributing to AKI, and dehydration should be managed but is not the primary role of the nurse in AKI management.
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