ATI LPN
PN ATI Capstone Maternal Newborn
1. A nurse is teaching the parent of a newborn about car seat safety. Which of the following statements should the nurse make?
- A. You should keep the car seat rear-facing until your baby is at least 2 years old.
- B. Position the retainer clip over the upper part of your baby's abdomen.
- C. You should place your baby in the car seat with a slight recline.
- D. Place the shoulder harness straps in the slots at or below your baby's shoulders.
Correct answer: A
Rationale: The correct answer is A. The car seat should remain rear-facing until the baby is at least 2 years old to ensure maximum safety in the event of a collision. This position helps protect the infant’s head, neck, and spine. Choice B is incorrect because the retainer clip should be positioned at armpit level on the baby, not over the upper part of the abdomen. Choice C is incorrect as the baby should be placed in the car seat with a slight recline, not at a 90-degree angle. Choice D is incorrect as the shoulder harness straps should be at or below the baby's shoulders, not above, to ensure proper fit and safety.
2. A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel telling the client, “If you don’t eat, I’ll put restraints on your wrists and feed you.†The nurse should intervene and explain to the AP that this statement constitutes which of the following torts?
- A. Assault
- B. Battery
- C. Malpractice
- D. Negligence
Correct answer: A
Rationale: The correct answer is A: Assault. Assault is the act of threatening a client with harm, such as the threat of using restraints to force-feed the client, even if no physical contact occurs. In this scenario, the statement made by the assistive personnel constitutes assault because it involves the threat of harm. Choice B, Battery, involves actual physical contact without the client's consent, which is not present in the scenario. Choice C, Malpractice, refers to professional negligence or misconduct, not a direct threat to the client. Choice D, Negligence, involves failure to provide reasonable care that results in harm, which is not applicable in this context.
3. 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.
4. A nurse is teaching a group of clients about measures to prevent the development of skin cancer. Which of the following client statements indicates a need for further teaching?
- A. I will avoid going outside between 1000 and 1600.
- B. I will wear a wide-brimmed hat when I go outside.
- C. I will make sure to apply sunscreen with SPF 10 when I’m in the sun.
- D. I will reapply my sunscreen every 2 hours.
Correct answer: C
Rationale: The correct answer is C. An SPF of at least 15 is recommended to effectively protect against harmful UV rays. A sunscreen with an SPF of 10 is insufficient and does not provide adequate protection against skin cancer. Choices A, B, and D demonstrate good understanding of sun protection measures, such as avoiding peak sun hours, wearing protective clothing like a wide-brimmed hat, and reapplying sunscreen every 2 hours, which are all effective strategies to prevent skin cancer.
5. A nurse is planning an education session for a client who has type 1 diabetes mellitus. Which of the following should the nurse plan to include when teaching the client to monitor for hypoglycemia?
- A. Diaphoresis
- B. Polyuria
- C. Abdominal pain
- D. Thirst
Correct answer: A
Rationale: The correct answer is A: Diaphoresis. Diaphoresis (sweating) is a classic symptom of hypoglycemia, along with shakiness, confusion, and irritability. These signs help indicate low blood sugar levels. Choices B, C, and D are incorrect. Polyuria (excessive urination), abdominal pain, and thirst are not typical symptoms associated with hypoglycemia. It is crucial for clients with type 1 diabetes mellitus to recognize the early signs of hypoglycemia to take prompt corrective action.
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