Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse in a clinic is caring for a client who is in her second trimester of pregnancy. The client expresses concern about preparing her 2-year-old child for a new sibling. Which of the following is an appropriate response by the nurse?
A. "Move your toddler to his new bed 2 months before the baby comes home.".
The nurse should not advise the client to "Move your toddler to his new bed 2 months before the baby comes home.”. This can disrupt the toddler's routine and create unnecessary stress during a significant transition in their life.
B. "Avoid bringing your toddler to prenatal visits.".
It is not appropriate to "Avoid bringing your toddler to prenatal visits.”. Involving the toddler in prenatal visits can help them adjust to the idea of a new sibling and reduce potential jealousy or feelings of being excluded.
C. "Let your toddler see you carrying the baby into the home for the first time.".
The correct answer is to "Let your toddler see you carrying the baby into the home for the first time.”. This approach allows the toddler to witness the arrival of the new sibling and can help them feel involved and excited about the new addition to the family.
D. "Require scheduled interactions between the toddler and the baby.".
"Require scheduled interactions between the toddler and the baby”. is not the best response. While it's essential to facilitate interactions between the toddler and the baby, forcing scheduled interactions may cause stress and resistance, especially if the toddler is not ready for such encounters.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Maternal Newborn 2019 NGN Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
The nurse should not advise the client to "Move your toddler to his new bed 2 months before the baby comes home.”. This can disrupt the toddler's routine and create unnecessary stress during a significant transition in their life.
Choice B rationale:
It is not appropriate to "Avoid bringing your toddler to prenatal visits.”. Involving the toddler in prenatal visits can help them adjust to the idea of a new sibling and reduce potential jealousy or feelings of being excluded.
Choice C rationale:
The correct answer is to "Let your toddler see you carrying the baby into the home for the first time.”. This approach allows the toddler to witness the arrival of the new sibling and can help them feel involved and excited about the new addition to the family.
Choice D rationale:
"Require scheduled interactions between the toddler and the baby”. is not the best response. While it's essential to facilitate interactions between the toddler and the baby, forcing scheduled interactions may cause stress and resistance, especially if the toddler is not ready for such encounters.
Similar Questions
A nurse is teaching a newly licensed nurse about the uses of ultrasonography in the first trimester of pregnancy. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
A. "Ultrasound is used to determine gestational age in the first trimester.".
Determining gestational age in the first trimester is a common and important use of ultrasound. It helps confirm the estimated due date and monitor the fetus's growth and development.
B. "Ultrasound is used to perform a biophysical profile in the first trimester.".
Performing a biophysical profile in the first trimester is not a common use of ultrasound. Biophysical profiles are usually performed in the second or third trimester to assess fetal well-being.
C. "Ultrasound is used to observe for placental maturity in the first trimester.".
Observing placental maturity in the first trimester is not a standard use of ultrasound. Placental maturity is typically assessed later in pregnancy, especially in the third trimester.
D. "Ultrasound is used to detect intrauterine growth restriction in the first trimester.".
Detecting intrauterine growth restriction in the first trimester is not a primary use of ultrasound. Intrauterine growth restriction is more commonly assessed in later stages of pregnancy when fetal growth is a concern.
Full Explanation
Choice A rationale:
Determining gestational age in the first trimester is a common and important use of ultrasound. It helps confirm the estimated due date and monitor the fetus's growth and development.
Choice B rationale:
Performing a biophysical profile in the first trimester is not a common use of ultrasound. Biophysical profiles are usually performed in the second or third trimester to assess fetal well-being.
Choice C rationale:
Observing placental maturity in the first trimester is not a standard use of ultrasound. Placental maturity is typically assessed later in pregnancy, especially in the third trimester.
Choice D rationale:
Detecting intrauterine growth restriction in the first trimester is not a primary use of ultrasound. Intrauterine growth restriction is more commonly assessed in the later stages of pregnancy when fetal growth is a concern.
A nurse is caring for a client who is in labour. Which of the following findings should prompt the nurse to reassess the client?
A. Intense contractions lasting 45 to 60 seconds.
Intense contractions lasting 45 to 60 seconds are normal during labor and indicate effective uterine activity. This finding does not warrant immediate reassessment.
B. Progressive sacral discomfort during contractions.
Progressive sacral discomfort during contractions can be a normal part of labor as the baby descends into the birth canal. It does not necessarily indicate a need for reassessment.
C. A sense of excitement and warm, flushed skin.
A sense of excitement and warm, flushed skin can be a common emotional and physiological response during labor, particularly as the woman reaches the final stages of delivery. This finding does not necessarily require immediate reassessment.
D. An urge to have a bowel movement during contractions.
"An urge to have a bowel movement during contractions”. is the correct answer because it could be an indication that the client is experiencing the urge to push, which means the baby's head is descending and nearing delivery. The nurse should reassess the client promptly to determine if she is fully dilated and ready to push.
Full Explanation
Choice A rationale:
Intense contractions lasting 45 to 60 seconds are normal during labour and indicate effective uterine activity. This finding does not warrant immediate reassessment.
Choice B rationale:
Progressive sacral discomfort during contractions can be a normal part of labour as the baby descends into the birth canal. It does not necessarily indicate a need for reassessment.
Choice C rationale:
A sense of excitement and warm, flushed skin can be a common emotional and physiological response during labour, particularly as the woman reaches the final stages of delivery. This finding does not necessarily require immediate reassessment.
Choice D rationale:
"An urge to have a bowel movement during contractions”. is the correct answer because it could be an indication that the client is experiencing the urge to push, which means the baby's head is descending and nearing delivery. The nurse should reassess the client promptly to determine if she is fully dilated and ready to push.
A nurse is caring for a newborn. Which of the following assessment findings should indicate to the nurse that suctioning of the nasopharynx is needed?
A. The newborn's respiratory rate is irregular.
An irregular respiratory rate in a newborn is not necessarily an indication for nasopharyngeal suctioning. Irregular respirations can have various causes, and suctioning may not be the appropriate intervention.
B. The newborn's respiratory rate is 32/min.
A respiratory rate of 32 breaths per minute is within the normal range for a newborn and does not indicate the need for nasopharyngeal suctioning.
C. The newborn's pulse oximetry is 91%.
A pulse oximetry reading of 91% is low and may indicate the need for intervention, but it does not specifically indicate the need for nasopharyngeal suctioning. Other interventions, such as supplemental oxygen, may be more appropriate.
D. The newborn is beginning to cough.
The newborn beginning to cough is a clear indication that there may be secretions or obstruction in the nasopharynx, and suctioning may be necessary to clear the airway and improve respiratory function.
Full Explanation
The correct answer is **d. The newborn is beginning to cough**.
Choice A rationale:
An irregular respiratory rate in a newborn is not necessarily an indication for nasopharyngeal suctioning. Irregular respirations can have various causes, and suctioning may not be the appropriate intervention.
Choice B rationale:
A respiratory rate of 32 breaths per minute is within the normal range for a newborn and does not indicate the need for nasopharyngeal suctioning.
Choice C rationale:
A pulse oximetry reading of 91% is low and may indicate the need for intervention, but it does not specifically indicate the need for nasopharyngeal suctioning. Other interventions, such as supplemental oxygen, may be more appropriate.
Choice D rationale:
The newborn beginning to cough is a clear indication that there may be secretions or obstruction in the nasopharynx, and suctioning may be necessary to clear the airway and improve respiratory function.