ATI LPN
PN ATI Capstone Maternal Newborn
1. A nurse is caring for a newborn who is 1 hour old and has a respiratory rate of 50 breaths per minute with periods of apnea lasting up to 10 seconds. Which of the following actions should the nurse take?
- A. Administer oxygen
- B. Stimulate the newborn
- C. Initiate positive pressure ventilation
- D. Continue routine monitoring
Correct answer: D
Rationale: A respiratory rate of 50 breaths per minute with occasional periods of apnea lasting less than 15 seconds is normal for a newborn. The nurse should continue routine monitoring unless the apneic periods become prolonged or the newborn shows signs of respiratory distress. Administering oxygen or initiating positive pressure ventilation is not indicated in this scenario as the newborn's respiratory rate and apneic episodes are within normal limits for their age. Stimulating the newborn is also unnecessary since the described parameters fall within the expected range for a 1-hour-old infant.
2. A healthcare provider is providing education on the use of atorvastatin. Which of the following should be included?
- A. Monitor for liver function
- B. It can cause muscle pain
- C. It is safe to take during pregnancy
- D. Both A and B
Correct answer: D
Rationale: Atorvastatin requires monitoring for liver function due to its potential to cause liver abnormalities. It can also lead to muscle pain or weakness, a condition known as myopathy. Choice C is incorrect as atorvastatin is contraindicated during pregnancy due to potential harm to the fetus, making choices A and B the correct options to include in patient education.
3. A nurse is providing teaching to a client who has a new prescription for lisinopril. Which of the following statements by the client indicates a need for further teaching?
- A. I will notify my doctor if I develop a cough.
- B. I will avoid using salt substitutes.
- C. I will increase my intake of potassium-rich foods.
- D. I will monitor my blood pressure regularly.
Correct answer: C
Rationale: The correct answer is C. Clients taking lisinopril should avoid potassium-rich foods because ACE inhibitors can increase potassium levels, potentially leading to hyperkalemia. Choices A, B, and D are all correct statements. Clients should notify their doctor if they develop a cough as it can indicate a potential side effect of lisinopril. Avoiding salt substitutes is important as they may contain potassium chloride, which can also raise potassium levels. Monitoring blood pressure regularly is essential when taking an antihypertensive medication like lisinopril.
4. A client wearing an arm cast reports numb fingers. Which of the following actions should the nurse take first?
- A. Place the arm in a dependent position
- B. Administer pain medication
- C. Check the client's circulation
- D. Apply a warm compress to the fingers
Correct answer: C
Rationale: The correct answer is to check the client's circulation. Numbness in the fingers may indicate compromised circulation or nerve damage. By assessing the circulation first, the nurse can ensure that the cast is not too tight, which could be cutting off blood flow. Option A is incorrect because placing the arm in a dependent position may worsen circulation issues. Option B is incorrect as administering pain medication does not address the underlying cause of numbness. Option D is incorrect as applying a warm compress could mask circulation issues and is not the priority in this situation.
5. A nurse is caring for a newborn who has respiratory distress. Which of the following actions should the nurse take first?
- A. Administer oxygen via nasal cannula
- B. Place the newborn in a prone position
- C. Suction the newborn's airway
- D. Notify the healthcare provider
Correct answer: C
Rationale: In cases of respiratory distress, the nurse should first suction the newborn's airway to clear any obstructions. This is a priority intervention as it helps ensure the airway is patent and allows for effective breathing. Administering oxygen, placing the newborn in a prone position, and notifying the healthcare provider are all important actions but should come after ensuring the airway is clear. Administering oxygen may not be effective if the airway is obstructed. Placing the newborn in a prone position can worsen respiratory distress in infants. While notifying the healthcare provider is important, immediate intervention to clear the airway takes precedence in this situation.
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