ATI LPN
PN ATI Capstone Maternal Newborn
1. A nurse is caring for a client who is experiencing preterm labor and has a new prescription for terbutaline. Which of the following findings is a contraindication for the administration of this medication?
- A. Heart disease
- B. Cervical dilation of 2 cm
- C. Gestational age of 34 weeks
- D. Allergy to penicillin
Correct answer: A
Rationale: The correct answer is A, heart disease. Terbutaline is contraindicated in clients with heart disease because it can lead to tachycardia and other cardiac complications due to its beta-agonist properties. Choice B, cervical dilation of 2 cm, is not a contraindication for terbutaline administration in preterm labor. Choice C, gestational age of 34 weeks, does not contraindicate the use of terbutaline for preterm labor. Choice D, allergy to penicillin, is not related to the contraindications of terbutaline.
2. A nurse is preparing to perform a sterile dressing change for a client with a surgical wound. Which action should the nurse take to prevent contamination during the dressing change?
- A. Proceed with the dressing change
- B. Restart the procedure if the sterile solution splashes onto the sterile field
- C. Continue without concern for minor splashes
- D. Delegate the task to another nurse
Correct answer: B
Rationale: The correct action for the nurse to take to prevent contamination during a sterile dressing change is to restart the procedure if the sterile solution splashes onto the sterile field. Any contamination of the sterile field compromises the aseptic technique and increases the risk of infection for the client. Therefore, it is crucial to maintain the sterility of the field throughout the procedure. Choices A, C, and D are incorrect because proceeding with the dressing change, continuing without concern for minor splashes, or delegating the task to another nurse would all compromise the sterility of the procedure and increase the risk of infection for the client.
3. A nurse is teaching a client about dietary modifications for a low-sodium diet. Which of the following should the nurse include?
- A. Limit intake of processed foods
- B. Increase intake of fresh fruits and vegetables
- C. Use of accessory muscles
- D. Monitor for allergic reactions
Correct answer: A
Rationale: The correct answer is to limit intake of processed foods. Processed foods are often high in sodium, which goes against the goal of a low-sodium diet. Fresh fruits and vegetables are recommended for a low-sodium diet due to their natural low sodium content. The use of accessory muscles and monitoring for allergic reactions are not related to dietary modifications for a low-sodium diet.
4. A healthcare provider is assessing a client with chronic obstructive pulmonary disease (COPD). Which of the following findings should the healthcare provider expect?
- A. Decreased respiratory rate
- B. Use of accessory muscles
- C. Improved lung sounds
- D. Increased energy levels
Correct answer: B
Rationale: The correct answer is B: 'Use of accessory muscles.' Clients with COPD often experience airway obstruction, leading to the use of accessory muscles to breathe. This compensatory mechanism helps them overcome the increased work of breathing. Choice A, 'Decreased respiratory rate,' is incorrect because clients with COPD typically have an increased respiratory rate due to the need for more effort to breathe. Choice C, 'Improved lung sounds,' is incorrect because COPD is characterized by wheezes, crackles, and diminished breath sounds. Choice D, 'Increased energy levels,' is incorrect because clients with COPD often experience fatigue due to the increased work of breathing and impaired gas exchange.
5. A nurse is preparing to administer total parenteral nutrition (TPN) to a client. Which of the following findings indicates a need to obtain a new bag of TPN before administering?
- A. The TPN solution has an oily appearance and a layer of fat on top of the solution.
- B. The TPN solution contains added electrolytes, vitamins, and trace elements.
- C. The bag of TPN was prepared by the pharmacy 12 hours prior.
- D. The bag of TPN is labeled with the client's name, medical record number, and prescription.
Correct answer: A
Rationale: A TPN solution with an oily appearance and a layer of fat on top indicates that the solution is 'cracked' and should not be used as it may have separated or deteriorated. This finding suggests a need to obtain a new bag of TPN before administering. Options B, C, and D are normal aspects of TPN administration. Option B confirms the presence of essential components in the TPN solution, option C provides information about the preparation time, and option D ensures proper identification and matching of the TPN with the correct client.
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