Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse in the labour and delivery unit is planning care for a client who has human immunodeficiency virus (HIV). Which of the following is an appropriate action for the nurse to take following the birth of the newborn?
A. Administer IV antibiotics to the newborn.
Administer IV antibiotics to the newborn. This is not necessary unless the newborn has signs of infection or sepsis. Antibiotics do not prevent or treat HIV infection.
B. Encourage the mother to breastfeed her newborn.
Encourage the mother to breastfeed her newborn. This is contraindicated for mothers with HIV, as breastfeeding can transmit the virus to the infant. Mothers with HIV should avoid breastfeeding and use formula or donor milk instead.
C. Cleanse the newborn immediately after delivery.
Cleanse the newborn immediately after delivery. This is because cleansing the newborn can reduce the risk of HIV transmission through exposure to maternal blood or fluids.
D. Initiate contact precautions for the newborn.
Initiate contact precautions for the newborn. This is not required for newborns exposed to HIV, as HIV is not transmitted by casual contact. Standard precautions are sufficient to prevent the spread of HIV and other bloodborne pathogens.
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
The correct answer is c. Cleanse the newborn immediately after delivery. This is because cleansing the newborn can reduce the risk of HIV transmission through exposure to maternal blood or fluids. The other options are not appropriate for the following reasons:
a. Administer IV antibiotics to the newborn. This is not necessary unless the newborn has signs of infection or sepsis. Antibiotics do not prevent or treat HIV infection.
b. Encourage the mother to breastfeed her newborn. This is contraindicated for mothers with HIV, as breastfeeding can transmit the virus to the infant. Mothers with HIV should avoid breastfeeding and use formula or donor milk instead.
d. Initiate contact precautions for the newborn. This is not required for newborns exposed to HIV, as HIV is not transmitted by casual contact. Standard precautions are sufficient to prevent the spread of HIV and other bloodborne pathogens.
Similar Questions
A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include?
A. Offer the newborn 30 mL (1 oz) of water between feedings.
Newborns who are exclusively breastfed do not require additional water between feedings. Breast milk provides all the necessary fluids to keep the baby hydrated.
B. Allow the baby to feed at least every 3 hr.
This instruction is generally appropriate. Newborns typically need to breastfeed frequently, usually at least every 2-3 hours, to ensure they receive adequate nutrition and to stimulate milk production in the mother. Therefore, this instruction should be included.
C. Feed the newborn 5 to 10 min per breast.
Newborns should be allowed to nurse on one breast until they are satisfied and then offered the other breast. Restricting feeding to a specific duration (5 to 10 minutes) on each breast may interfere with adequate feeding and hinder milk production.
D. Expect two to four wet diapers every 24 hr.
This instruction is generally appropriate. Monitoring the frequency of wet diapers is an essential way to assess whether the newborn is adequately hydrated and receiving enough breast milk. Generally, newborns should have at least six wet diapers a day, which indicates adequate fluid intake.
A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?
A. Rust-stained urine.
Rust-stained urine is typically due to urate crystals and is common in newborns. It usually resolves on its own and is not a cause for concern.
B. Single palmar creases.
Single palmar creases can be associated with certain genetic conditions, such as Down syndrome. This finding should be reported to the provider for further evaluation.
C. Subconjunctival hemorrhage.
Subconjunctival hemorrhage is a common finding in newborns due to the pressure changes during delivery. It usually resolves without intervention and is not typically a cause for concern.
D. Transient circumoral cyanosis.
Transient circumoral cyanosis is often seen in newborns and can occur when the baby is crying or feeding. It usually resolves on its own and is not typically a cause for concern.
Full Explanation
The correct answer is choice B. Single palmar creases.
Choice A rationale:
Rust-stained urine is typically due to urate crystals and is common in newborns. It usually resolves on its own and is not a cause for concern.
Choice B rationale:
Single palmar creases can be associated with certain genetic conditions, such as Down syndrome. This finding should be reported to the provider for further evaluation.
Choice C rationale:
Subconjunctival hemorrhage is a common finding in newborns due to the pressure changes during delivery. It usually resolves without intervention and is not typically a cause for concern.
Choice D rationale:
Transient circumoral cyanosis is often seen in newborns and can occur when the baby is crying or feeding. It usually resolves on its own and is not typically a cause for concern.
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.
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.