Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
What advice should the nurse give the client?
A. Take acetaminophen.
While acetaminophen can help reduce fever, it does not address the underlying cause of the client’s symptoms. Moreover, self-medication without proper medical advice can potentially harm the pregnancy.
B. Come in for an immediate evaluation.
The client’s symptoms of low-grade fever, moderate cramping, and heavy bright-red bleeding could indicate a serious condition such as a miscarriage or an ectopic pregnancy. Therefore, immediate medical evaluation is necessary.
C. Monitor the flow of the vaginal bleeding.
While monitoring the flow of vaginal bleeding can provide useful information, it does not address the immediate need for medical evaluation given the client’s symptoms.
D. Rest in a supine position at home.
Resting at home might not be the best advice given the severity of the client’s symptoms. Immediate medical evaluation is necessary.
This question is an excerpt from Nurse Dive's nursing test bank - Care Hope College RN HESI Maternity Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale
While acetaminophen can help reduce fever, it does not address the underlying cause of the client’s symptoms. Moreover, self-medication without proper medical advice can potentially harm the pregnancy.
Choice B rationale
The client’s symptoms of low-grade fever, moderate cramping, and heavy bright-red bleeding could indicate a serious condition such as a miscarriage or an ectopic pregnancy. Therefore, immediate medical evaluation is necessary.
Choice C rationale
While monitoring the flow of vaginal bleeding can provide useful information, it does not address the immediate need for medical evaluation given the client’s symptoms.
Choice D rationale
Resting at home might not be the best advice given the severity of the client’s symptoms. Immediate medical evaluation is necessary.
Similar Questions
A new mother, who is breastfeeding her 4-week-old infant and has type I diabetes, reports that her insulin needs have decreased since the birth of her child.
What action should the nurse take?
A. Counsel her to increase her caloric intake.
While increasing caloric intake can be beneficial for breastfeeding mothers, it does not directly address the client’s concern about decreased insulin needs.
B. Advise the client to breastfeed more frequently.
Advising the client to breastfeed more frequently does not directly address the client’s concern about decreased insulin needs.
C. Inform her that a decreased need for insulin occurs while breastfeeding.
Breastfeeding can lead to a decreased need for insulin in some individuals. This is because lactation requires energy, and this energy demand can affect the mother’s insulin requirements.
D. Schedule an appointment for the client with the diabetic nurse educator.
While scheduling an appointment with the diabetic nurse educator can be helpful, it is not the immediate response to the client’s concern about decreased insulin needs.
Full Explanation
Choice A rationale
While increasing caloric intake can be beneficial for breastfeeding mothers, it does not directly address the client’s concern about decreased insulin needs.
Choice B rationale
Advising the client to breastfeed more frequently does not directly address the client’s concern about decreased insulin needs.
Choice C rationale
Breastfeeding can lead to a decreased need for insulin in some individuals. This is because lactation requires energy, and this energy demand can affect the mother’s insulin requirements.
Choice D rationale
While scheduling an appointment with the diabetic nurse educator can be helpful, it is not the immediate response to the client’s concern about decreased insulin needs.
What physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?
A. Unilateral lower leg pain.
Unilateral lower leg pain is not a normal finding postpartum and could indicate a deep vein thrombosis, which requires immediate medical attention.
B. Soft, spongy fundus.
A soft, spongy fundus is not a normal finding postpartum. The uterus should be firm to prevent excessive bleeding.
C. Pulse rate of 56 beats/minute.
A pulse rate of 56 beats/minute can be a normal finding postpartum. Pregnancy increases blood volume and cardiac output, and these changes can persist for some time after delivery.
D. Saturating two perineal pads per hour.
Saturating two perineal pads per hour is not a normal finding postpartum and could indicate excessive bleeding.
Full Explanation
Choice A rationale
Unilateral lower leg pain is not a normal finding postpartum and could indicate a deep vein thrombosis, which requires immediate medical attention.
Choice B rationale
A soft, spongy fundus is not a normal finding postpartum. The uterus should be firm to prevent excessive bleeding.
Choice C rationale
A pulse rate of 56 beats/minute can be a normal finding postpartum. Pregnancy increases blood volume and cardiac output, and these changes can persist for some time after delivery.
Choice D rationale
Saturating two perineal pads per hour is not a normal finding postpartum and could indicate excessive bleeding.
A multiparous client at 36-hours postpartum reports increased bleeding and cramping. On examination, the nurse finds the uterine fundus 2 cm above the umbilicus.
What action should the nurse take first?
A. Call the healthcare provider.
While notifying the healthcare provider is important, it is not the first action to take. The nurse should first address the immediate issue of a potentially full bladder that could be displacing the uterus.
B. Encourage the client to void.
Encouraging the client to void can help if the bladder is full. A full bladder can displace the uterus and interfere with uterine contractions, leading to increased bleeding.
C. Administer ibuprofen 800 mg by mouth.
Administering ibuprofen can help with cramping, but it does not address the immediate issue of a potentially full bladder displacing the uterus.
D. Increase the intravenous fluid to 150 mL/hour.
Increasing the intravenous fluid rate is not the first action to take. The nurse should first address the immediate issue of a potentially full bladder displacing the uterus.
Full Explanation
Choice A rationale
While notifying the healthcare provider is important, it is not the first action to take. The nurse should first address the immediate issue of a potentially full bladder that could be displacing the uterus.
Choice B rationale
Encouraging the client to void can help if the bladder is full. A full bladder can displace the uterus and interfere with uterine contractions, leading to increased bleeding.
Choice C rationale
Administering ibuprofen can help with cramping, but it does not address the immediate issue of a potentially full bladder displacing the uterus.
Choice D rationale
Increasing the intravenous fluid rate is not the first action to take. The nurse should first address the immediate issue of a potentially full bladder displacing the uterus.