ATI LPN
PN ATI Capstone Maternal Newborn
1. A nurse is caring for a newborn with hyperbilirubinemia. Which of the following interventions should be taken during phototherapy?
- A. Maintain an eye mask over the newborn's eyes
- B. Feed the newborn every hour
- C. Monitor the newborn's temperature
- D. Administer vitamin K
Correct answer: A
Rationale: During phototherapy for a newborn with hyperbilirubinemia, it is crucial to maintain an eye mask over the newborn's eyes. The purpose of the eye mask is to protect the infant's eyes from potential damage caused by the intense light used in phototherapy. While feeding the newborn frequently and monitoring temperature are essential aspects of newborn care, they are not specific to phototherapy. Administering vitamin K is important for newborns to prevent bleeding disorders but is not directly related to phototherapy for hyperbilirubinemia.
2. A nurse is reviewing the guidelines for reporting nationally notifiable infectious diseases. What disease should the nurse report to the CDC?
- A. Measles
- B. Hepatitis A
- C. Lyme disease
- D. Zika
Correct answer: C
Rationale: The correct answer is Lyme disease. Lyme disease must be reported to the CDC as it is a nationally notifiable infectious disease. It is spread by ticks and can lead to significant health issues if not monitored. Measles, Hepatitis A, and Zika are also important infectious diseases, but in this case, Lyme disease is the appropriate choice based on the information provided.
3. A healthcare provider is assessing a client who is receiving IV gentamicin three times daily. Which of the following findings indicates that the client is experiencing an adverse effect of this medication?
- A. Hypoglycemia
- B. Proteinuria
- C. Nasal congestion
- D. Visual disturbances
Correct answer: B
Rationale: Corrected Rationale: Gentamicin is known to cause nephrotoxicity as an adverse effect. Proteinuria, which is the presence of excess proteins in the urine, may indicate kidney damage from the medication. Monitoring renal function is crucial in clients receiving gentamicin. Choice A, hypoglycemia, is not a typical adverse effect of gentamicin. Choices C and D, nasal congestion and visual disturbances, are not commonly associated with gentamicin use or its adverse effects.
4. A nurse is caring for a client 4 hours postoperative following a thyroidectomy. The client reports fullness in the throat. What should the nurse assess for?
- A. Hypocalcemia
- B. Hemorrhage
- C. Hypoxia
- D. Hypothyroidism
Correct answer: B
Rationale: In this scenario, the correct answer is B: Hemorrhage. Fullness in the throat post-thyroidectomy can indicate postoperative bleeding, a critical complication that requires immediate assessment and intervention. Choice A, Hypocalcemia, is incorrect because it does not typically present with fullness in the throat. Choice C, Hypoxia, is not directly related to the symptom described and is not the primary concern in this situation. Choice D, Hypothyroidism, is also incorrect as it is a long-term condition and unlikely to manifest suddenly 4 hours postoperatively with throat fullness.
5. A nurse is caring for a client prescribed clopidogrel. Which of the following should the nurse monitor?
- A. Liver function tests
- B. Blood pressure
- C. Potassium levels
- D. Respiratory rate
Correct answer: A
Rationale: Corrected Rationale: Clopidogrel is an antiplatelet medication, so the nurse should monitor for signs of bleeding and liver function tests due to potential liver effects. Monitoring liver function tests is essential to detect any adverse effects on the liver because clopidogrel can cause hepatotoxicity. While monitoring blood pressure, potassium levels, and respiratory rate are important in general patient care, they are not the priority assessments specifically related to clopidogrel use.
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