ATI LPN
PN ATI Capstone Maternal Newborn
1. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings should the nurse report to the healthcare provider?
- A. Urinary output of 40 mL/hr
- B. Respiratory rate of 10 breaths per minute
- C. Absent deep tendon reflexes
- D. Blood pressure of 150/90 mm Hg
Correct answer: B
Rationale: Magnesium sulfate can depress the central nervous system, leading to respiratory depression. A respiratory rate of 10 breaths per minute is below the normal range and requires immediate intervention. Urinary output of 40 mL/hr (Choice A) is within the normal range for a client receiving magnesium sulfate. Absent deep tendon reflexes (Choice C) are an expected finding due to the medication's effect on neuromuscular excitability. A blood pressure of 150/90 mm Hg (Choice D) is slightly elevated but not a priority concern compared to severe respiratory depression.
2. A nurse is sitting with the partner of a client who recently died. Which action should the nurse take to facilitate mourning?
- A. Offer advice on coping strategies
- B. Encourage the partner to ask for help when needed
- C. Discuss the importance of grieving alone
- D. Suggest the partner avoid talking about the loss
Correct answer: B
Rationale: Encouraging the partner to ask for help when needed is the most appropriate action for the nurse to facilitate mourning. Grieving is a challenging process, and individuals may require support from others to cope effectively. Offering advice on coping strategies, discussing the importance of grieving alone, or suggesting avoiding talking about the loss could hinder the partner's mourning process by isolating them or suppressing their feelings.
3. A healthcare professional is assessing a client in the PACU. Which finding indicates decreased cardiac output?
- A. Shivering
- B. Oliguria
- C. Bradypnea
- D. Constricted pupils
Correct answer: B
Rationale: The correct answer is B: Oliguria. Oliguria (low urine output) is a sign of decreased cardiac output because the kidneys are not receiving enough blood to produce an adequate amount of urine. Shivering (choice A) is a response to hypothermia or the body's attempt to generate heat. Bradypnea (choice C) refers to abnormally slow breathing rate and is not directly related to cardiac output. Constricted pupils (choice D) are more indicative of conditions affecting the nervous system or medications.
4. A nurse is checking laboratory results for a client. Which of the following laboratory findings indicates hypervolemia?
- A. Serum sodium 138 mEq/L
- B. Urine specific gravity 1.001
- C. Serum calcium 10 mg/dL
- D. Urine pH 6
Correct answer: B
Rationale: The correct answer is B. A urine specific gravity of 1.001 is low and indicates dilute urine, which is a sign of fluid overload (hypervolemia). Choice A, serum sodium 138 mEq/L, is within the normal range and does not indicate hypervolemia. Choice C, serum calcium 10 mg/dL, is not typically used to diagnose hypervolemia. Choice D, urine pH 6, is also not a specific indicator of hypervolemia.
5. A client is taking levothyroxine. Which of the following findings should indicate that the medication is effective?
- A. Weight loss
- B. Decreased blood pressure
- C. Absence of seizures
- D. Decreased inflammation
Correct answer: A
Rationale: The correct answer is A: Weight loss. Levothyroxine is used to treat hypothyroidism, which is characterized by symptoms such as weight gain. Therefore, weight loss in a client taking levothyroxine indicates that the medication is effective in managing hypothyroidism. Choices B, C, and D are incorrect because levothyroxine primarily affects thyroid function and metabolism, not blood pressure, seizures, or inflammation.
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