ATI LPN
ATI Maternal Newborn
1. A client who is postpartum has a slightly boggy and displaced fundus to the right. Which of the following actions should the nurse take based on these findings?
- A. Encourage the client to perform Kegel exercises.
- B. Encourage the client to move to the left lateral position.
- C. Ask the client to rate her pain.
- D. Assist the client to the bathroom to void.
Correct answer: D
Rationale: A displaced and boggy fundus in a postpartum client typically indicates a full bladder, which can impede uterine contractions and increase the risk of postpartum hemorrhage. Assisting the client to the bathroom to void helps ensure the bladder is empty, aiding the fundus to contract and reducing the risk of complications. Encouraging Kegel exercises, changing positions, or assessing pain would not directly address the issue of the boggy fundus caused by a full bladder.
2. After returning the client to bed following a cardiac catheterization procedure with the left femoral vessel as the access site, the nurse places a sign above the bed instructing the client to remain on bed rest and in which position?
- A. In semi-Fowler's position
- B. With the head of the bed elevated 45 degrees
- C. With the head of the bed elevated no more than 15 degrees
- D. With the foot of the bed elevated as much as tolerated by the client
Correct answer: C
Rationale: After cardiac catheterization via the femoral vessel, it is crucial to keep the head of the bed elevated no more than 15 degrees to prevent bleeding at the access site. This position helps maintain pressure on the femoral artery, reducing the risk of bleeding and complications post-procedure. Choices A, B, and D are incorrect because they do not provide the necessary pressure on the femoral artery to prevent bleeding, which is essential after a cardiac catheterization procedure with a femoral access site.
3. A nurse is caring for a client with an NG tube who is experiencing nausea and decreased gastric secretions. What is the priority nursing action?
- A. Increase the suction pressure
- B. Turn the client onto their side
- C. Irrigate the NG tube with sterile water
- D. Replace the NG tube with a new one
Correct answer: D
Rationale: The correct answer is to replace the NG tube with a new one. When a client with an NG tube experiences nausea and decreased gastric secretions, it indicates a possible problem with the tube itself. Replacing the tube ensures proper functioning and can alleviate the symptoms. Increasing the suction pressure (Choice A) can worsen the client's condition. Turning the client onto their side (Choice B) may be helpful in some situations but does not address the underlying issue. Irrigating the NG tube with sterile water (Choice C) is not the priority and may not resolve the problem.
4. The caregiver is teaching a new mother about infant safety. Which statement indicates that further teaching is needed?
- A. I will place my baby on their back to sleep.
- B. I will keep soft toys and pillows out of the crib.
- C. I will use a car seat for every car ride.
- D. I will allow my baby to sleep in my bed.
Correct answer: D
Rationale: Allowing a baby to sleep in an adult bed increases the risk of suffocation and Sudden Infant Death Syndrome (SIDS). It is safer for infants to sleep on a firm, flat surface in their own crib or bassinet to reduce the risk of accidental suffocation or strangulation. Therefore, the caregiver should be advised against co-sleeping with the infant to ensure the baby's safety.
5. A child newly diagnosed with diabetes mellitus has been stabilized with insulin injections daily. A nurse prepares a discharge teaching plan regarding the insulin. The teaching plan should reinforce which of the following concepts?
- A. Always store insulin vials in the refrigerator
- B. Adjust insulin dosage before exercise
- C. Presence of ketones in urine indicates a need for less insulin
- D. Systematically rotate injection sites
Correct answer: D
Rationale: Systematically rotating injection sites is crucial to prevent tissue damage and ensure optimal insulin absorption. This practice helps in preventing lipohypertrophy, a condition characterized by fat accumulation at injection sites, which can affect insulin absorption and lead to inconsistent blood glucose control. By rotating injection sites, the risk of skin and tissue damage is minimized, and insulin's effectiveness is maintained over time.
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