ATI LPN
Maternal Newborn ATI Proctored Exam 2023
1. A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan?
- A. Monitor the client's blood pressure every hour.
- B. Restrict the total hourly intake to 200 mL.
- C. Monitor the FHR continuously.
- D. Administer protamine sulfate for manifestations of toxicity.
Correct answer: C
Rationale: The correct answer is C. When a client with preeclampsia is receiving magnesium sulfate via continuous IV infusion, it is crucial to monitor the fetal heart rate (FHR) continuously. Magnesium sulfate is given to prevent seizures and is considered a high-alert medication that requires close monitoring, especially of FHR and uterine contractions. Monitoring the client's blood pressure every hour, as in choice A, is important but not as crucial as continuous FHR monitoring. Restricting the total hourly intake to 200 mL, as in choice B, is not a relevant intervention for a client receiving magnesium sulfate. Administering protamine sulfate for manifestations of toxicity, as in choice D, is incorrect as protamine sulfate is not the antidote for magnesium sulfate toxicity.
2. When assessing a 30-year-old female who was sexually assaulted, what is the MOST important action for you to take?
- A. Have a female healthcare provider perform the assessment.
- B. Advise against showering or changing clothes.
- C. Acknowledge that the patient is a potential crime scene.
- D. Ensure that all life-threatening injuries are treated.
Correct answer: D
Rationale: In cases of sexual assault, the priority is to address any life-threatening injuries first before proceeding with other aspects of care. Although preserving evidence and approaching the situation with sensitivity are crucial, immediate treatment of life-threatening conditions takes precedence to ensure the patient's well-being and safety. Having a female healthcare provider, advising against showering or changing clothes, and acknowledging the patient as a potential crime scene are important but secondary considerations compared to addressing any life-threatening injuries promptly.
3. What assessment finding places a newborn at risk for developing physiologic jaundice?
- A. Cephalohematoma
- B. Mongolian spots
- C. Telangiectatic nevi
- D. Molding
Correct answer: A
Rationale: The correct answer is A, Cephalohematoma. Physiologic jaundice in newborns can occur due to the breakdown of excess red blood cells. A cephalohematoma, a collection of blood caused by ruptured blood vessels between a cranial bone's surface and periosteal membrane, can lead to increased red blood cell breakdown. This increased breakdown can contribute to the development of physiologic jaundice in newborns. Choices B, Mongolian spots, and C, Telangiectatic nevi, are both benign skin conditions and are not directly associated with increased red blood cell breakdown. Choice D, Molding, refers to the shaping of the fetal head during passage through the birth canal and is not related to the development of physiologic jaundice.
4. A nurse is reviewing the plan of care for a client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse include?
- A. Apply heat to the affected area
- B. Place the client in a prone position
- C. Turn and reposition the client every 2 hours
- D. Provide the client with a bedpan every 4 hours
Correct answer: C
Rationale: The correct intervention for a client at risk for pressure ulcers is to turn and reposition the client every 2 hours. This helps relieve pressure on bony prominences, improving circulation and reducing the risk of pressure ulcer development. Applying heat to the affected area (Choice A) can increase the risk of skin breakdown. Placing the client in a prone position (Choice B) can also increase pressure on certain areas, leading to pressure ulcers. Providing the client with a bedpan every 4 hours (Choice D) is not directly related to preventing pressure ulcers.
5. A nurse is planning to delegate to an AP the task of fasting blood glucose testing for a client who has diabetes mellitus. Which of the following actions should the nurse take?
- A. Determine if the AP is qualified to perform the test
- B. Help the AP perform the blood glucose test
- C. Assign the AP to ask the client if they have taken diabetic medication today
- D. Have the AP check the medical record for prior blood glucose test results
Correct answer: A
Rationale: Before delegating any task, the nurse must determine whether the AP is qualified to perform it. In this scenario, verifying the AP's competency to conduct fasting blood glucose testing is crucial for patient safety and compliance with facility protocols. The other choices are incorrect because they do not address the essential step of assessing the AP's ability to perform the delegated task. While helping the AP or assigning tasks related to diabetic medication or medical records are important, the primary concern should be confirming the AP's competence for the specific delegated duty of blood glucose testing.
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