ATI Capstone EXAM 2 Questions and
Answers 3 versions
Question 1:
A nurse is assessing a client who is 12 hours postpartum following a vaginal
delivery. The client's fundus is firm, midline, and at the level of the
umbilicus. The client reports a gush of blood and a clot the size of a golf
ball when ambulating to the bathroom. Which action should the nurse take
first?
A) Massage the fundus vigorously
B) Increase the IV oxytocin infusion rate
C) Assess the perineal pad for saturation
D) Notify the provider immediately
Correct Answer: C) Assess the perineal pad for saturation
Rationale: The priority is to assess the actual amount of bleeding by checking
the perineal pad. A gush with ambulation can be normal due to vaginal
pooling, but quantification is needed first. Massaging a firm fundus is
contraindicated, and provider notification comes after assessment.
Question 2:
A nurse is caring for a client at 38 weeks gestation with preeclampsia with
severe features. Which finding should the nurse report to the provider
immediately?
,A) Blood pressure 152/94 mm Hg
B) Urinary output 25 mL over 2 hours
C) 1+ protein in urine
D) Mild headache that resolves with rest
Correct Answer: B) Urinary output 25 mL over 2 hours
Rationale: Output <30 mL/hour indicates decreased renal perfusion and
worsening preeclampsia. This is a critical sign that requires immediate
intervention. The other findings are concerning but not as urgent.
Question 3:
A nurse is preparing to administer magnesium sulfate IV to a client with
severe preeclampsia. Which medication should the nurse have readily
available as an antidote?
A) Naloxone
B) Flumazenil
C) Calcium gluconate
D) Protamine sulfate
Correct Answer: C) Calcium gluconate
Rationale: Calcium gluconate is the antidote for magnesium sulfate toxicity.
Signs of toxicity include loss of deep tendon reflexes, respiratory depression,
and cardiac arrest. Naloxone is for opioid overdose, flumazenil for
benzodiazepines, and protamine for heparin.
Question 4:
A nurse is assessing a newborn who is 5 minutes old. The heart rate is
,140/min, respiratory effort is crying, muscle tone is active, reflex irritability is
grimacing, and color is pink with blue extremities. What is the Apgar score?
A) 7
B) 8
C) 9
D) 10
Correct Answer: C) 9
Rationale: The score is 9 because color is 1 point (pink body, blue extremities).
Heart rate (2), respiratory effort (2), muscle tone (2), and reflex irritability (1
for grimace) total 9. A perfect 10 requires pink all over.
Question 5:
A nurse is teaching a client about signs of preterm labor. Which statement
indicates understanding?
A) "I will call if I have back pain that comes and goes."
B) "I will call if I feel fetal movement more than 10 times per hour."
C) "I will call if I have urinary frequency without burning."
D) "I will call if I have a weight gain of 1 pound in a week."
Correct Answer: A) "I will call if I have back pain that comes and goes."
Rationale: Low back pain that is rhythmic and comes and goes can be a sign
of preterm labor. Fetal movement, urinary frequency, and gradual weight
gain are normal findings.
Question 6:
A nurse is caring for a client with placenta previa. Which finding requires
immediate intervention?
, A) Painless bright red vaginal bleeding
B) Intermittent contractions every 10 minutes
C) Fetal heart rate of 150/min
D) Blood pressure 118/76 mm Hg
Correct Answer: A) Painless bright red vaginal bleeding
Rationale: Painless bright red bleeding is the classic sign of placenta previa
and indicates active bleeding. This requires immediate notification of the
provider and preparation for possible delivery. A digital exam is
contraindicated.
Question 7:
A nurse is assessing a client who has just received epidural anesthesia
during labor. Which finding indicates an adverse reaction?
A) Blood pressure 90/60 mm Hg
B) Respiratory rate 16/min
C) Fetal heart rate 145/min
D) Urinary output 60 mL/hour
Correct Answer: A) Blood pressure 90/60 mm Hg
Rationale: Hypotension is a common adverse effect of epidural anesthesia
due to sympathetic blockade. The nurse should increase IV fluids, position the
client laterally, and administer oxygen. The other values are within normal
limits.
Question 8:
A nurse is providing discharge teaching to a postpartum client who is
breastfeeding. Which statement indicates a need for further teaching?
Answers 3 versions
Question 1:
A nurse is assessing a client who is 12 hours postpartum following a vaginal
delivery. The client's fundus is firm, midline, and at the level of the
umbilicus. The client reports a gush of blood and a clot the size of a golf
ball when ambulating to the bathroom. Which action should the nurse take
first?
A) Massage the fundus vigorously
B) Increase the IV oxytocin infusion rate
C) Assess the perineal pad for saturation
D) Notify the provider immediately
Correct Answer: C) Assess the perineal pad for saturation
Rationale: The priority is to assess the actual amount of bleeding by checking
the perineal pad. A gush with ambulation can be normal due to vaginal
pooling, but quantification is needed first. Massaging a firm fundus is
contraindicated, and provider notification comes after assessment.
Question 2:
A nurse is caring for a client at 38 weeks gestation with preeclampsia with
severe features. Which finding should the nurse report to the provider
immediately?
,A) Blood pressure 152/94 mm Hg
B) Urinary output 25 mL over 2 hours
C) 1+ protein in urine
D) Mild headache that resolves with rest
Correct Answer: B) Urinary output 25 mL over 2 hours
Rationale: Output <30 mL/hour indicates decreased renal perfusion and
worsening preeclampsia. This is a critical sign that requires immediate
intervention. The other findings are concerning but not as urgent.
Question 3:
A nurse is preparing to administer magnesium sulfate IV to a client with
severe preeclampsia. Which medication should the nurse have readily
available as an antidote?
A) Naloxone
B) Flumazenil
C) Calcium gluconate
D) Protamine sulfate
Correct Answer: C) Calcium gluconate
Rationale: Calcium gluconate is the antidote for magnesium sulfate toxicity.
Signs of toxicity include loss of deep tendon reflexes, respiratory depression,
and cardiac arrest. Naloxone is for opioid overdose, flumazenil for
benzodiazepines, and protamine for heparin.
Question 4:
A nurse is assessing a newborn who is 5 minutes old. The heart rate is
,140/min, respiratory effort is crying, muscle tone is active, reflex irritability is
grimacing, and color is pink with blue extremities. What is the Apgar score?
A) 7
B) 8
C) 9
D) 10
Correct Answer: C) 9
Rationale: The score is 9 because color is 1 point (pink body, blue extremities).
Heart rate (2), respiratory effort (2), muscle tone (2), and reflex irritability (1
for grimace) total 9. A perfect 10 requires pink all over.
Question 5:
A nurse is teaching a client about signs of preterm labor. Which statement
indicates understanding?
A) "I will call if I have back pain that comes and goes."
B) "I will call if I feel fetal movement more than 10 times per hour."
C) "I will call if I have urinary frequency without burning."
D) "I will call if I have a weight gain of 1 pound in a week."
Correct Answer: A) "I will call if I have back pain that comes and goes."
Rationale: Low back pain that is rhythmic and comes and goes can be a sign
of preterm labor. Fetal movement, urinary frequency, and gradual weight
gain are normal findings.
Question 6:
A nurse is caring for a client with placenta previa. Which finding requires
immediate intervention?
, A) Painless bright red vaginal bleeding
B) Intermittent contractions every 10 minutes
C) Fetal heart rate of 150/min
D) Blood pressure 118/76 mm Hg
Correct Answer: A) Painless bright red vaginal bleeding
Rationale: Painless bright red bleeding is the classic sign of placenta previa
and indicates active bleeding. This requires immediate notification of the
provider and preparation for possible delivery. A digital exam is
contraindicated.
Question 7:
A nurse is assessing a client who has just received epidural anesthesia
during labor. Which finding indicates an adverse reaction?
A) Blood pressure 90/60 mm Hg
B) Respiratory rate 16/min
C) Fetal heart rate 145/min
D) Urinary output 60 mL/hour
Correct Answer: A) Blood pressure 90/60 mm Hg
Rationale: Hypotension is a common adverse effect of epidural anesthesia
due to sympathetic blockade. The nurse should increase IV fluids, position the
client laterally, and administer oxygen. The other values are within normal
limits.
Question 8:
A nurse is providing discharge teaching to a postpartum client who is
breastfeeding. Which statement indicates a need for further teaching?
