ATI RN
ATI Capstone Maternal Newborn Assessment Quizlet
1. A nurse is providing care for a client who is in active labor and receiving oxytocin. Which of the following findings should the nurse report to the provider?
- A. Contraction frequency of 2 minutes
- B. Contraction duration of 90 seconds
- C. Fetal heart rate of 150/min
- D. Urine output of 60 mL/hr
Correct answer: B
Rationale: A contraction duration of 90 seconds can indicate uterine tachysystole, which may lead to fetal hypoxia. Uterine tachysystole is defined as more than five contractions in 10 minutes, averaged over a 30-minute window. Contractions every 2 minutes (Choice A) may occur in active labor but need to be assessed in conjunction with other factors. A fetal heart rate of 150/min (Choice C) is within the normal range. Urine output of 60 mL/hr (Choice D) is also within the expected range for a client in labor.
2. A 26-year-old female with type 1 diabetes develops a sore throat and runny nose after caring for her sick toddler. The patient calls the clinic for advice about her symptoms and a blood glucose level of 210 mg/dL despite taking her usual glargine (Lantus) and lispro (Humalog) insulin. The nurse advises the patient to
- A. use only the lispro insulin until the symptoms are resolved
- B. limit calorie intake until the glucose is less than 120 mg/dL
- C. monitor blood glucose every 4 hours and notify the clinic if it continues to rise
- D. decrease carbohydrate intake until glycosylated hemoglobin is less than 7%
Correct answer: C
Rationale: In this scenario, the nurse should advise the patient to monitor her blood glucose every 4 hours and notify the clinic if it continues to rise. This is important because the patient is experiencing symptoms of an illness (sore throat and runny nose) that can lead to fluctuations in blood glucose levels. By monitoring frequently, any significant rise in blood glucose can be detected early, enabling prompt intervention. Choice A is incorrect because abruptly stopping glargine (Lantus) insulin can lead to uncontrolled blood glucose levels. Choice B is incorrect as limiting calorie intake is not the appropriate immediate action for managing high blood glucose levels. Choice D is also incorrect as adjusting carbohydrate intake based on glycosylated hemoglobin levels is not the immediate action needed in this acute situation.
3. A healthcare provider is reviewing a client's health record and notes that the client experiences permanent extrapyramidal effects caused by a previous medication. The healthcare provider should recognize that the medication affected which of the following systems in the client?
- A. Cardiovascular
- B. Immune
- C. Central nervous
- D. Gastrointestinal
Correct answer: C
Rationale: The correct answer is C: Central nervous. Extrapyramidal effects are movement disorders that can be caused by certain medications affecting the central nervous system, such as typical antipsychotic medications. These effects can lead to symptoms like tremors, muscle rigidity, and involuntary movements, which are all related to disruptions in the central nervous system. Choices A, B, and D are incorrect because extrapyramidal effects are specifically associated with the central nervous system and not the cardiovascular, immune, or gastrointestinal systems.
4. New evidence suggests that __________.
- A. there is very little cultural diversity in human development
- B. environmental, but not personal, contexts shape development
- C. development occurs in a neat, orderly sequence of stages unaffected by distinct contexts
- D. people not only are affected by but also contribute to the contexts in which they develop Answer: D Page Ref: 6 Skill Level: Understand Topic: Basic Issues Difficulty Level: Difficult
Correct answer: D
Rationale: The correct answer is D because the statement aligns with the concept of reciprocal influences in human development. The new evidence suggests that individuals are not only influenced by the contexts in which they develop but also contribute to shaping those contexts. This idea highlights the dynamic and interactive nature of human development, emphasizing the bidirectional relationship between individuals and their environments.
5. The client with cirrhosis has ascites and excess fluid volume. Which measure will the nurse include in the plan of care for this client?
- A. Increase the amount of sodium in the diet.
- B. Limit the amount of fluids consumed.
- C. Encourage frequent ambulation.
- D. Administer magnesium antacids.
Correct answer: B
Rationale: Excess fluid volume, related to the accumulation of fluid in the peritoneal and dependent areas of the body, can occur in the client with cirrhosis. Fluids should be restricted, including fluids given in medications and meals. Sodium restriction also aids in reducing fluid volume excess.
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