Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A newborn is admitted with a diagnosis of a spiral fracture of the right femur. The mother states the child received the injury when the baby fell off the changing table. Which would be the priority nursing intervention?
A. Call the child abuse hotline
Call the child abuse hotline. A spiral fracture, especially in a non-ambulatory infant, is highly suspicious for non-accidental trauma (child abuse). Reporting suspected abuse is mandatory to protect the child from further harm.
B. Educate the mother on safety
Educate the mother on safety. While important for prevention, addressing potential abuse takes precedence.
C. Inform the mother to call the nurse for all diaper changes
Inform the mother to call the nurse for all diaper changes. This does not address the immediate concern of suspected child abuse.
D. Complete the Morse Fall Scale
Complete the Morse Fall Scale. This is irrelevant in the context of suspected child abuse.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Nur 209 Reproductive Health Proctored Exam. Take the full exam now
Full Explanation
A. Call the child abuse hotline. A spiral fracture, especially in a non-ambulatory infant, is highly suspicious for non-accidental trauma (child abuse). Reporting suspected abuse is mandatory to protect the child from further harm.
B. Educate the mother on safety. While important for prevention, addressing potential abuse takes precedence.
C. Inform the mother to call the nurse for all diaper changes. This does not address the immediate concern of suspected child abuse.
D. Complete the Morse Fall Scale. This is irrelevant in the context of suspected child abuse.
Similar Questions
When caring for a postpartum client the nurse notes that the client's perineal pad is saturated with bright red blood. What is the priority question to ask the client?
A. Have you passed any clots?
Have you passed any clots? This is important to assess for potential postpartum hemorrhage, which can be indicated by passage of large clots.
B. Do you have to go to the bathroom?
Do you have to go to the bathroom? This does not directly address the issue of excessive bleeding.
C. When was the last time you changed your pad?
When was the last time you changed your pad? This provides information about the amount of bleeding but does not address clotting.
D. Are you having any cramping?
Are you having any cramping? Cramping is common postpartum but does not directly assess for hemorrhage.
Full Explanation
A. Have you passed any clots? This is important to assess for potential postpartum hemorrhage, which can be indicated by passage of large clots.
B. Do you have to go to the bathroom? This does not directly address the issue of excessive bleeding.
C. When was the last time you changed your pad? This provides information about the amount of bleeding but does not address clotting.
D. Are you having any cramping? Cramping is common postpartum but does not directly assess for hemorrhage.
A nurse is discussing postpartum depression with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of this condition?
A. "The most common manifestation of postpartum depression is harming the infant."
"The most common manifestation of postpartum depression is harming the infant." This is incorrect; harming the infant is a severe complication but not the most common manifestation.
B. "It's common for clients who have postpartum depression to exhibit psychotic behavior."
"It's common for clients who have postpartum depression to exhibit psychotic behavior." Psychotic behavior is a rare but serious complication of postpartum depression.
C. "Postpartum depression usually begins 48 hours after childbirth."
"Postpartum depression usually begins 48 hours after childbirth." Postpartum blues may start within this timeframe, but postpartum depression typically manifests later.
D. "Postpartum depression is more likely to occur in women who have a history of depression."
"Postpartum depression is more likely to occur in women who have a history of depression." This statement correctly identifies a significant risk factor for postpartum depression.
Full Explanation
A. "The most common manifestation of postpartum depression is harming the infant." This is incorrect; harming the infant is a severe complication but not the most common manifestation.
B. "It's common for clients who have postpartum depression to exhibit psychotic behavior." Psychotic behavior is a rare but serious complication of postpartum depression.
C. "Postpartum depression usually begins 48 hours after childbirth." Postpartum blues may start within this timeframe, but postpartum depression typically manifests later.
D. "Postpartum depression is more likely to occur in women who have a history of depression." This statement correctly identifies a significant risk factor for postpartum depression.
Which statements made by the parent indicate that appropriate care is being provided to a 4-year-old who has spastic type cerebral palsy? (Select All that Apply.)
A. I perform range of motion exercises every 4 hours to help prevent contractures
I perform a range of motion exercises every 4 hours to help prevent contractures. This helps prevent the tightening of muscles and joints, reducing the risk of contractures common in spastic cerebral palsy.
B. I make sure that I use toys and activities that are appropriate for my child's chronological age
I make sure that I use toys and activities that are appropriate for my child's chronological age. While important, this does not specifically address the care needs related to spastic cerebral palsy.
C. I have utensils with large, padded handles to make it easier for my child to feed himself
I have utensils with large, padded handles to make it easier for my child to feed himself. Adaptive utensils promote independence in self-care activities.
D. I play games with my child every day to keep them as independent as possible
I play games with my child every day to keep them as independent as possible. Engaging in activities that promote independence and social interaction is beneficial for children with cerebral palsy.
E. I give my child carbidopa so that he will stop drooling
I give my child carbidopa so that he will stop drooling. Medications like carbidopa are not typically used to manage drooling associated with cerebral palsy and are not a primary care measure.
Full Explanation
A. I perform a range of motion exercises every 4 hours to help prevent contractures. This helps prevent the tightening of muscles and joints, reducing the risk of contractures common in spastic cerebral palsy.
B. I make sure that I use toys and activities that are appropriate for my child's chronological age. While important, this does not specifically address the care needs related to spastic cerebral palsy.
C. I have utensils with large, padded handles to make it easier for my child to feed himself. Adaptive utensils promote independence in self-care activities.
D. I play games with my child every day to keep them as independent as possible. Engaging in activities that promote independence and social interaction is beneficial for children with cerebral palsy.
E. I give my child carbidopa so that he will stop drooling. Medications like carbidopa are not typically used to manage drooling associated with cerebral palsy and are not a primary care measure.