Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
What recommendation should the nurse provide?
A. Pump breasts every few hours.
Pumping breasts every few hours can stimulate milk production, which is not the goal for a formula-feeding mother.
B. Latch the baby on to feed for just a few minutes.
Latching the baby on to feed for just a few minutes can also stimulate milk production, which is not the goal for a formula-feeding mother.
C. Change breast pads often.
Changing breast pads often is a good practice for breastfeeding mothers to maintain hygiene and prevent infections, but it does not directly address the issue of painful, hard, and full breasts in a formula-feeding mother.
D. Wear a form-fitting bra for the next couple of days.
Wearing a form-fitting bra for the next couple of days can provide support and help reduce the discomfort associated with engorgement in a formula-feeding mother.
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
Pumping breasts every few hours can stimulate milk production, which is not the goal for a formula-feeding mother.
Choice B rationale
Latching the baby on to feed for just a few minutes can also stimulate milk production, which is not the goal for a formula-feeding mother.
Choice C rationale
Changing breast pads often is a good practice for breastfeeding mothers to maintain hygiene and prevent infections, but it does not directly address the issue of painful, hard, and full breasts in a formula-feeding mother.
Choice D rationale
Wearing a form-fitting bra for the next couple of days can provide support and help reduce the discomfort associated with engorgement in a formula-feeding mother.
Similar Questions
A 16-year-old client, who is pregnant for the first time and has no children, has been admitted to the hospital with a diagnosis of eclampsia.
She is not currently convulsing.
What intervention should the nurse plan to include in this client’s nursing care plan?
A. Monitor blood pressure, pulse, and respirations every 4 hours.
While monitoring vital signs is important in a client with eclampsia, it should be done more frequently than every 4 hours due to the risk of seizures and other complications.
B. Keep an airway at the bedside.
Keeping an airway at the bedside is crucial for a client with eclampsia. If a seizure occurs, the airway can be used to ensure the client’s airway remains open.
C. Allow liberal family visitation.
Liberal family visitation may not be appropriate for a client with eclampsia who needs a quiet and stress-free environment to prevent triggering seizures.
D. Assess temperature every hour.
Assessing temperature every hour is not specifically related to the care of a client with eclampsia.
Full Explanation
Choice A rationale
While monitoring vital signs is important in a client with eclampsia, it should be done more frequently than every 4 hours due to the risk of seizures and other complications.
Choice B rationale
Keeping an airway at the bedside is crucial for a client with eclampsia. If a seizure occurs, the airway can be used to ensure the client’s airway remains open.
Choice C rationale
Liberal family visitation may not be appropriate for a client with eclampsia who needs a quiet and stress-free environment to prevent triggering seizures.
Choice D rationale
Assessing temperature every hour is not specifically related to the care of a client with eclampsia.
The nurse is providing preconception counseling.
Which supplement should the nurse recommend to help prevent the occurrence of anencephaly?
A. Calcium.
Calcium is essential for the development of fetal bones and teeth, but it is not specifically linked to preventing neural tube defects like anencephaly.
B. Folic acid.
Folic acid is vital for preventing neural tube defects, including anencephaly. It’s recommended for women of childbearing age and especially during the early stages of pregnancy.
C. Vitamin D.
Vitamin D is important for bone health, but its primary function is not directly related to preventing neural tube defects like anencephaly.
D. Iron.
Iron is crucial for preventing anemia in pregnancy, supporting increased blood volume. However, it is not directly associated with preventing neural tube defects.
Full Explanation
Choice A rationale
Calcium is essential for the development of fetal bones and teeth, but it is not specifically linked to preventing neural tube defects like anencephaly.
Choice B rationale
Folic acid is vital for preventing neural tube defects, including anencephaly. It’s recommended for women of childbearing age and especially during the early stages of pregnancy.
Choice C rationale
Vitamin D is important for bone health, but its primary function is not directly related to preventing neural tube defects like anencephaly.
Choice D rationale
Iron is crucial for preventing anemia in pregnancy, supporting increased blood volume. However, it is not directly associated with preventing neural tube defects.
The nurse observes on the fetal monitor that a laboring client has a variable deceleration. What action should the nurse implement first?
A. Administer oxygen via facemask.
Administering oxygen via facemask is a common intervention for variable decelerations, but it is not the first action that should be taken.
B. Change the client’s position.
Changing the client’s position is the recommended first action for variable decelerations. Repositioning the mother, such as moving her to a lateral or knee-chest position, can relieve potential cord compression and improve fetal oxygenation.
C. Turn off the oxytocin infusion.
Turning off the oxytocin infusion is another intervention for variable decelerations, but it is not the first action that should be taken.
D. Assess cervical dilatation.
Assessing cervical dilation is not the first action that should be taken in response to variable decelerations.
Full Explanation
Choice A rationale
Administering oxygen via facemask is a common intervention for variable decelerations, but it is not the first action that should be taken.
Choice B rationale
Changing the client’s position is the recommended first action for variable decelerations. Repositioning the mother, such as moving her to a lateral or knee-chest position, can relieve potential cord compression and improve fetal oxygenation.
Choice C rationale
Turning off the oxytocin infusion is another intervention for variable decelerations, but it is not the first action that should be taken.
Choice D rationale
Assessing cervical dilation is not the first action that should be taken in response to variable decelerations.