ATI LPN
PN ATI Capstone Maternal Newborn
1. A nurse is providing teaching to a client who is at 34 weeks of gestation and is scheduled for a nonstress test. Which of the following statements should the nurse plan to make?
- A. You will not receive medication through an IV for this test.
- B. You should expect the test to take about 30 minutes.
- C. You do not need to eat or drink for 4 hours prior to the test.
- D. This test will help determine if your baby's lungs are mature.
Correct answer: B
Rationale: The correct statement for the nurse to make is choice B, 'You should expect the test to take about 30 minutes.' The nonstress test is used to assess fetal well-being by monitoring fetal heart rate in response to movements. Choice A is incorrect because medications are not typically administered during a nonstress test. Choice C is incorrect as there is no need for the client to fast before the test. Choice D is incorrect because determining fetal lung maturity is usually done through other tests, not the nonstress test.
2. What is the primary intervention for sepsis?
- A. Administer IV antibiotics
- B. Monitor blood pressure
- C. Administer fluids
- D. All of the above
Correct answer: D
Rationale: The primary intervention for sepsis involves a multifaceted approach, including administering IV antibiotics to address the underlying infection and administering fluids to stabilize the patient's hemodynamic status. Monitoring blood pressure is important in the management of sepsis, but it is not the sole primary intervention. Therefore, the correct answer is 'All of the above' as it encompasses the comprehensive approach required for effective sepsis management.
3. While assessing a client with fluid volume deficit, which of the following findings should the nurse expect?
- A. Bradycardia
- B. Increased skin turgor
- C. Dry mucous membranes
- D. Hypertension
Correct answer: C
Rationale: Dry mucous membranes are a classic clinical manifestation of fluid volume deficit. Dehydration leads to reduced fluid intake or excessive fluid loss, resulting in decreased moisture in the mucous membranes. Bradycardia, increased skin turgor, and hypertension are not typically associated with fluid volume deficit. Bradycardia is more commonly seen in conditions like hypothyroidism or increased intracranial pressure. Increased skin turgor is a sign of dehydration, not deficit. Hypertension is not a typical finding in fluid volume deficit.
4. A nurse is preparing to perform a sterile dressing change for a client who has a surgical wound. Which of the following actions should the nurse take to prevent contamination during the dressing change?
- A. Use sterile gloves only as necessary
- B. Restart the procedure if the sterile solution splashes onto the sterile field while pouring the solution into the dressing tray
- C. Keep the dressing tray on a nearby surface
- D. Avoid speaking during the procedure
Correct answer: B
Rationale: The correct action to prevent contamination during a sterile dressing change is to restart the procedure if the sterile solution splashes onto the sterile field while pouring the solution into the dressing tray. Any contact with the sterile field by non-sterile items makes the field contaminated and requires restarting the procedure to maintain sterility. Choice A is incorrect because sterile gloves should always be used during a sterile procedure to prevent contamination. Choice C is incorrect as the dressing tray should be placed on a sterile surface, not on the client's bed, to maintain sterility. Choice D is also incorrect as talking during the procedure does not necessarily lead to contamination if proper aseptic technique is maintained.
5. What are common risk factors for urinary tract infections (UTIs)?
- A. Poor hygiene and dehydration
- B. Increased sexual activity and pregnancy
- C. Use of urinary catheters and prolonged bed rest
- D. Family history and obesity
Correct answer: A
Rationale: The correct answer is A: Poor hygiene and dehydration are common risk factors for urinary tract infections (UTIs). While choices B, C, and D may play a role in certain cases, poor hygiene and dehydration are more universally recognized as key factors contributing to UTIs. Increased sexual activity and pregnancy (choice B) can also increase the risk of UTIs, but they are not as universal as poor hygiene and dehydration. Choices C and D, the use of urinary catheters and prolonged bed rest, and family history and obesity, respectively, are risk factors for UTIs but are not as commonly associated as poor hygiene and dehydration.
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