ATI LPN
Maternal Newborn ATI Proctored Exam 2023
1. A client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?
- A. Check the client's temperature.
- B. Observe for uterine contractions.
- C. Administer Rho(D) immune globulin.
- D. Monitor the fetal heart rate (FHR).
Correct answer: D
Rationale: After an amniocentesis, the priority nursing intervention is to monitor the fetal heart rate (FHR) as the greatest risk to the client and fetus is fetal death. This monitoring helps in early identification of any fetal distress or compromise, allowing prompt intervention to ensure fetal well-being. Checking the client's temperature (Choice A) is not the priority as monitoring the fetus is crucial for immediate assessment. Observing for uterine contractions (Choice B) is important but not the priority after an amniocentesis. Administering Rho(D) immune globulin (Choice C) is typically done to Rh-negative clients after procedures that may lead to fetal-maternal hemorrhage, not immediately after an amniocentesis.
2. A client with IV fluids has developed redness and warmth at the IV site. What is the next step the nurse should take?
- A. Apply a cold compress to the IV site
- B. Discontinue the IV and notify the healthcare provider
- C. Monitor the IV site for signs of infection
- D. Increase the IV flow rate to improve circulation
Correct answer: B
Rationale: When a client develops redness and warmth at the IV site, it is indicative of phlebitis, which is inflammation of the vein. The next step for the nurse should be to discontinue the IV and notify the healthcare provider. Applying a cold compress may provide temporary relief but does not address the underlying issue. Monitoring for infection is important, but in this case, the presence of redness and warmth suggests phlebitis, not infection. Increasing the IV flow rate can exacerbate the inflammation and should be avoided.
3. A nurse is caring for a client who is experiencing chronic pain. Which of the following interventions should the nurse implement?
- A. Provide the client with distractions such as television
- B. Administer pain medication around the clock
- C. Teach the client relaxation techniques
- D. Perform massage therapy on the client
Correct answer: C
Rationale: The correct intervention for a client experiencing chronic pain is to teach relaxation techniques, as it helps in managing pain more effectively by reducing stress and anxiety. Distractions like television (Choice A) may offer temporary relief but do not address the root cause of chronic pain. Administering pain medication around the clock (Choice B) may lead to dependency and not promote long-term pain management. While massage therapy (Choice D) can be beneficial, teaching relaxation techniques (Choice C) is more directly focused on empowering the client to manage their pain independently.
4. A nurse is teaching dietary guidelines to a client who has celiac disease. Which of the following food choices is appropriate for the client?
- A. White flour tortillas.
- B. Potato pancakes.
- C. Wheat crackers.
- D. Canned barley soup.
Correct answer: B
Rationale: The correct answer is B, potato pancakes. Individuals with celiac disease must avoid gluten-containing foods. Potato pancakes are gluten-free, making them a suitable choice for someone with celiac disease. Choice A, white flour tortillas, contains gluten from wheat flour, making it unsuitable for a client with celiac disease. Choice C, wheat crackers, also contain gluten and should be avoided. Choice D, canned barley soup, contains barley which is a gluten-containing grain and is not appropriate for someone with celiac disease.
5. A client is admitted to the hospital with a diagnosis of pericarditis. The nurse reviews the client's record for which sign or symptom that differentiates pericarditis from other cardiopulmonary problems?
- A. Anterior chest pain
- B. Pericardial friction rub
- C. Weakness and irritability
- D. Chest pain that worsens with inspiration
Correct answer: B
Rationale: Pericardial friction rub is a distinctive sign of pericarditis, characterized by a scraping or grating sound heard on auscultation, which helps differentiate pericarditis from other cardiopulmonary conditions. While anterior chest pain may be present in various cardiopulmonary issues, it is not specific to pericarditis. Weakness and irritability are nonspecific symptoms that can be seen in many conditions. Chest pain worsening with inspiration is more indicative of pleuritic conditions such as pleurisy or pneumonia, rather than pericarditis.
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