ATI RN
ATI Capstone Maternal Newborn Assessment Quizlet
1. A client who is postpartum reports abdominal cramping during breastfeeding. Which of the following actions should the nurse take?
- A. Administer ibuprofen
- B. Administer oxytocin
- C. Place a warm compress on the client's abdomen
- D. Assist the client to change positions
Correct answer: A
Rationale: Abdominal cramping during breastfeeding is common due to the release of oxytocin. Ibuprofen, an analgesic, is suitable for relieving discomfort. Administering oxytocin is unnecessary and may exacerbate the cramping. Placing a warm compress may not address the underlying cause of the cramping. Changing positions may provide temporary relief but does not address the cause of the cramping.
2. During an initial visit with an older adult client living alone and having difficulty preparing meals, what should the home health nurse do first?
- A. Discuss nutritional requirements with the client.
- B. Refer the client to a senior citizen center.
- C. Arrange for a home-delivered meal program.
- D. Perform a nutrition screening.
Correct answer: D
Rationale: Performing a nutrition screening is the most appropriate action for the nurse to take first. This allows the nurse to assess the client's current nutritional status and identify any specific needs. Discussing nutritional requirements with the client (Choice A) may be important but should come after the initial assessment. Referring the client to a senior citizen center (Choice B) or arranging for a home-delivered meal program (Choice C) are actions that may be considered later based on the findings of the nutrition screening.
3. After surgery, a patient is experiencing pain. What is the nurse's priority action?
- A. Administer pain medication as prescribed.
- B. Assess the patient's pain using a pain scale.
- C. Offer the patient non-pharmacological pain relief methods.
- D. Reassess the patient's pain level after 30 minutes.
Correct answer: B
Rationale: The correct answer is to assess the patient's pain using a pain scale. This is the priority action because it allows the nurse to obtain an objective measure of the patient's pain intensity. By accurately assessing the pain level, the nurse can determine the appropriate intervention, which may include administering pain medication as prescribed (choice A) or offering non-pharmacological pain relief methods (choice C). Reassessing the patient's pain level after 30 minutes (choice D) is important but comes after the initial assessment to evaluate the effectiveness of the interventions implemented.
4. As children grow and develop, their style of play changes. Which play style is descriptive of the school-age child?
- A. Plays alone but not with other children
- B. Plays games with other children and is able to follow the rules of the game
- C. Plays alone with play directed by others
- D. Plays with others in loose groups
Correct answer: B
Rationale: The correct answer is B. School-age children are typically able to play structured games with other children and follow the rules of the game. This ability reflects their growing cognitive and social development. Choice A is incorrect as school-age children often engage in group play. Choice C is incorrect as school-age children usually have more autonomy in their play choices. Choice D is incorrect as school-age children tend to form more organized play settings rather than loose groups.
5. A nurse is assessing a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings should the nurse report to the provider?
- A. Respiratory rate 16/min.
- B. Blood pressure 118/78 mm Hg.
- C. Urinary output of 30 mL/hr.
- D. Absent deep-tendon reflexes.
Correct answer: D
Rationale: The correct answer is D. Absent deep-tendon reflexes indicate magnesium toxicity and should be reported immediately. Magnesium sulfate is used to prevent seizures in clients with preeclampsia, but toxicity can lead to serious complications, including respiratory depression and loss of deep-tendon reflexes. Choices A, B, and C are within normal limits and expected findings in a client receiving magnesium sulfate for preeclampsia, so they do not require immediate reporting.
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