Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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.
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 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.
Similar Questions
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.
At 20-weeks gestation, a client who has gained 20 pounds (9.1 kg) during this pregnancy tells the nurse that she is feeling fetal movement.
Fundal height measurement is 20 cm, and the client’s only complaint is that her breasts are leaking clear fluid. Which assessment finding warrants further evaluation?
A. Leakage from breasts.
Leakage of clear fluid from the breasts towards the end of the second trimester into the third trimester is normal. This fluid is colostrum, a precursor to breastmilk, and its presence indicates breast development in preparation for lactation.
B. Gestational weight gain.
An average weight gain during pregnancy is 25 to 35 pounds. In the second trimester, a woman should be gaining about 1 pound per week. A weight gain of 20 pounds by 20 weeks indicates the client is on track or has even gained slightly more than expected. However, further evaluation is important as excessive weight gain in pregnancy might be indicative of underlying conditions such as preeclampsia or gestational diabetes.
C. Presence of fetal movement.
Fetal movement, also known as quickening, is a normal and expected occurrence around 18-20 weeks' gestation. It is a positive sign of fetal development and well-being.
D. Fundal height measurement.
Fundal height is the measure from the pubic symphysis to the top of the uterus. It is an indicator of fetal growth. A fundal height of 20cm at 20 weeks gestation suggests the pregnancy is progressing normally and the baby is growing appropriately.
Full Explanation
Choice A rationale
Leakage of clear fluid from the breasts towards the end of the second trimester into the third trimester is normal. This fluid is colostrum, a precursor to breastmilk, and its presence indicates breast development in preparation for lactation.
Choice B rationale
An average weight gain during pregnancy is 25 to 35 pounds. In the second trimester, a woman should be gaining about 1 pound per week. A weight gain of 20 pounds by 20 weeks indicates the client is on track or has even gained slightly more than expected. However, further evaluation is important as excessive weight gain in pregnancy might be indicative of underlying conditions such as preeclampsia or gestational diabetes.
Choice C rationale
Fetal movement, also known as quickening, is a normal and expected occurrence around 18-20 weeks' gestation. It is a positive sign of fetal development and well-being.
Choice D rationale
Fundal height is the measure from the pubic symphysis to the top of the uterus. It is an indicator of fetal growth. A fundal height of 20cm at 20 weeks gestation suggests the pregnancy is progressing normally and the baby is growing appropriately.