ATI LPN
PN ATI Capstone Maternal Newborn
1. A healthcare provider is caring for a client with severe preeclampsia. Which of the following medications should the healthcare provider anticipate administering?
- A. Magnesium sulfate
- B. Oxytocin
- C. Misoprostol
- D. Nifedipine
Correct answer: A
Rationale: Magnesium sulfate is the correct answer as it is administered to prevent seizures in clients with severe preeclampsia. It acts as a central nervous system depressant and is the first-line treatment for eclampsia prevention. Oxytocin (Choice B) is used to induce or augment labor, not indicated specifically for preeclampsia. Misoprostol (Choice C) is used for labor induction and postpartum hemorrhage, not typically indicated for preeclampsia. Nifedipine (Choice D) is a calcium channel blocker used for managing hypertension in pregnancy but is not the first-line treatment for preventing seizures in severe preeclampsia.
2. A client just received their first dose of lisinopril. Which of the following is an appropriate nursing intervention?
- A. Place the client on cardiac monitoring
- B. Monitor the client’s oxygen saturation
- C. Provide standby assistance when the client gets out of bed
- D. Encourage foods high in potassium
Correct answer: C
Rationale: The correct answer is to provide standby assistance when the client gets out of bed. Lisinopril can cause hypotension, especially after the first dose, which can lead to dizziness and falls. Standby assistance helps prevent potential injury. Placing the client on cardiac monitoring (choice A) or monitoring oxygen saturation (choice B) are not typically necessary after the first dose of lisinopril unless specific symptoms are present. Encouraging foods high in potassium (choice D) is not directly related to the immediate concern of postural hypotension associated with lisinopril.
3. A healthcare professional is assessing a client for signs of fluid overload. Which of the following findings should the healthcare professional look for?
- A. Weight loss
- B. Decreased blood pressure
- C. Edema
- D. Increased urine output
Correct answer: C
Rationale: Edema is a common sign of fluid overload. When the body retains more fluid than it excretes, it can lead to edema, which is swelling caused by excess fluid trapped in body tissues. Weight gain, not weight loss, is typically associated with fluid overload due to the retained fluids. Decreased blood pressure is more commonly associated with dehydration rather than fluid overload. Increased urine output is a sign of the body trying to eliminate excess fluids, which is contrary to the signs of fluid overload.
4. A nurse is caring for a client in active labor. The nurse notes variable decelerations in the fetal heart rate. Which of the following is the priority nursing action?
- A. Administer oxygen
- B. Reposition the client
- C. Prepare for delivery
- D. Increase IV fluids
Correct answer: B
Rationale: The correct answer is to reposition the client. Variable decelerations are often caused by umbilical cord compression. Repositioning the client can help alleviate pressure on the cord and improve fetal oxygenation. Administering oxygen may be necessary in some situations, but repositioning the client takes precedence to address the underlying cause of variable decelerations. While preparing for delivery is important, addressing the immediate concern of variable decelerations by repositioning the client is the priority. Increasing IV fluids is not the priority in this situation as it does not directly address the cause of variable decelerations.
5. A nurse is caring for a client who is 38 weeks pregnant and has a history of herpes simplex virus 2. Which question is most appropriate for the nurse to ask?
- A. Have your membranes ruptured?
- B. How far apart are your contractions?
- C. Do you have any active lesions?
- D. Are you positive for beta strep?
Correct answer: C
Rationale: The most appropriate question for the nurse to ask is whether the client has any active herpes lesions. This is crucial because the presence of active lesions can necessitate a cesarean section to prevent transmission of the virus to the newborn. Asking about membrane rupture (choice A) is important but not directly related to the client's herpes simplex virus 2 status. Inquiring about the frequency of contractions (choice B) is relevant for assessing labor progression but does not address the immediate concern of herpes transmission. Asking about being positive for beta strep (choice D) is important for determining the need for prophylactic antibiotics during labor, but it is not directly related to the client's herpes simplex virus 2 status.
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