ATI LPN
PN ATI Capstone Maternal Newborn
1. A nurse is caring for a client who is 8 hours postpartum following a vaginal birth. The client reports passing large clots and heavy bleeding. Which of the following actions should the nurse take?
- A. Massage the fundus
- B. Administer methylergonovine
- C. Increase the IV fluid rate
- D. Notify the healthcare provider
Correct answer: A
Rationale: Heavy bleeding and the passage of large clots after childbirth can indicate uterine atony. The nurse should first attempt to massage the fundus to stimulate uterine contractions and control the bleeding. Massaging the fundus helps the uterus to contract and may help prevent further bleeding. Administering methylergonovine (Choice B) is not the initial intervention for uterine atony. Increasing the IV fluid rate (Choice C) may not address the underlying cause of the bleeding. Notifying the healthcare provider (Choice D) can be done after attempting initial interventions like fundal massage.
2. In orienting new staff nurses to a pediatric intensive care unit, what is an important consideration in providing information to parents of a critically ill child?
- A. Making sure they receive complete information during each encounter
- B. Assessing parents' preferences regarding the amount of information
- C. Allowing parents to observe key aspects of their child's care
- D. Providing patient education brochures explaining ICU protocols
Correct answer: B
Rationale: Assessing parents' preferences about the amount of information is crucial because it allows for individualized care that respects their needs and emotional capacity during a stressful time. Choice A is not ideal as overwhelming parents with complete information during each encounter may not align with their preferences. Choice C, while valuable, may not always be feasible or appropriate due to privacy concerns or medical procedures. Choice D, providing brochures, may not address the specific needs or preferences of each set of parents, making it less effective than assessing individual preferences.
3. A nurse is caring for a client prescribed sildenafil for erectile dysfunction. Which of the following should the nurse monitor?
- A. Blood pressure
- B. Heart rate
- C. Temperature
- D. Respiratory rate
Correct answer: A
Rationale: The correct answer is A: Blood pressure. Sildenafil, a medication for erectile dysfunction, can cause changes in blood pressure. The nurse should monitor for hypotension as a potential side effect. Monitoring heart rate (choice B) is not a priority when administering sildenafil unless there are pre-existing heart conditions. Temperature (choice C) and respiratory rate (choice D) are typically not directly affected by sildenafil administration, making them less relevant for monitoring in this case.
4. A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect?
- A. Pruritus
- B. Hypertension
- C. Bradykinesia
- D. Xerostomia
Correct answer: C
Rationale: The correct answer is C: Bradykinesia. Bradykinesia, which refers to slowness of movement, is a characteristic symptom of Parkinson's disease. Other common manifestations in Parkinson's disease include tremors, muscle rigidity, orthostatic hypotension, and drooling. Pruritus (choice A) is unrelated to Parkinson's disease. While hypertension (choice B) can coexist with Parkinson's disease due to autonomic dysfunction, it is not a specific hallmark manifestation. Xerostomia (choice D) is not a primary symptom associated with Parkinson's disease.
5. A client has a stool culture positive for C. difficile. What action should the nurse take?
- A. Place the client in a negative pressure room
- B. Use alcohol-based hand rub after providing care
- C. Wear a face shield before entering the room
- D. Place the client in a private room
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.
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