Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a client who is in preterm labor and has a new prescription for terbutaline 0.25 mg subcutaneous.
For which of the following findings should the nurse withhold the medication and report to the provider?
A. BP 88/58 mm Hg
Terbutaline is a medication that can cause serious side effects such as ante (low blood pressure). A blood pressure reading of 88/58 mm Hg is considered low and could be a sign of hypotension. The nurse should withhold the medication and report this finding to the provider.
B. Urinary output 40 mL/hr
Choice B is not an answer because a urinary output of 40 mL/hr is within the normal range.
C. FHR 120/min.
Choice D is not an answer because a fetal heart rate (FHR) of 120/min is within the normal range.
D. Fasting blood glucose 75 mg/dL
Choice C is not an answer because a fasting blood glucose level of 75 mg/dL is within the normal range.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Maternal Newborn 2019 with NGN Proctored Exam. Take the full exam now
Full Explanation
Terbutaline is a medication that can cause serious side effects such as ante (low blood pressure).
A blood pressure reading of 88/58 mm Hg is considered low and could be a sign
of hypotension.
The nurse should withhold the medication and report this finding to the provider.
Choice B is not an answer because a urinary output of 40 mL/hr is within the
normal range.
Choice C is not an answer because a fetal heart rate (FHR) of 120/min is within the normal range.
Choice D is not an answer because a fasting blood glucose level of 75 mg/dL is
within the normal range.
Similar Questions
A client who is at 16 weeks of gestation asks a nurse how to prepare her toddler to have a younger sibling.
Which of the following statements should the nurse make?
A. "You should place your toddler in time-out if she exhibits regressive behavior after the baby is born."
B. "You should move your toddler out of her crib 2 weeks prior to your due date."
C. You should hold your newborn in your arms when you introduce him to your toddler."
D. "You should tell your toddler that the baby will need all your attention, but they will still be important."
A. "You should place your toddler in time-out if she exhibits regressive behavior
Choice A: This approach is not suitable for dealing with regressive behaviors in toddlers. Regressive behavior, such as wanting to sleep in the crib or revert to bottle-feeding, is a normal response to the stress of a new sibling. Instead of punishment, parents should provide reassurance, comfort, and understanding. Time-outs may exacerbate feelings of insecurity rather than alleviate them.
B. "You should move your toddler out of her crib 2 weeks prior to your due date."
Choice B: While transitioning a toddler out of the crib can be a part of preparation, it should not be rushed. Doing so too early may create unnecessary stress for the toddler. The best time to make significant changes (like transitioning to a bed) is when the toddler is ready, and it should be done with care and gradual preparation, not too close to the arrival of the baby.
C. "You should hold your newborn in your arms when you introduce him to your toddler.”
Choice C: This is the most appropriate advice. It’s important to allow the toddler to feel involved and included in the process, but holding the newborn during the introduction helps minimize feelings of jealousy and ensures the toddler doesn't feel displaced. Holding the baby allows the toddler to approach the situation more calmly, and it can also help foster a sense of love and comfort for both the toddler and the newborn.
D. "You should tell your toddler that the baby will need all your attention, but they will still be important."
“While it’s important to reassure the toddler that they are still loved and important, this statement might unintentionally increase anxiety or make the toddler feel less valued. Instead, the nurse should encourage a positive approach, where the toddler can learn how to be a helper and feel involved in the care of the newborn. It’s essential to focus on inclusivity rather than highlighting potential feelings of neglect.
Full Explanation
Correct answer: C- "You should hold your newborn in your arms when you introduce him to your toddler.”
Choice A is not an answer because this approach is not suitable for dealing with regressive behaviors in toddlers. Regressive behavior, such as wanting to sleep in the crib or revert to bottle-feeding, is a normal response to the stress of a new sibling. Instead of punishment, parents should provide reassurance, comfort, and understanding. Time-outs may exacerbate feelings of insecurity rather than alleviate them.
Choice B is not an answer because While transitioning a toddler out of the crib can be a part of preparation, it should not be rushed. Doing so too early may create unnecessary stress for the toddler. The best time to make significant changes (like transitioning to a bed) is when the toddler is ready, and it should be done with care and gradual preparation, not too close to the arrival of the baby.
Choice C is the most appropriate answer because It’s important to allow the toddler to feel involved and included in the process, but holding the newborn during the introduction helps minimize feelings of jealousy and ensures the toddler doesn't feel displaced. Holding the baby allows the toddler to approach the situation more calmly, and it can also help foster a sense of love and comfort for both the toddler and the newborn.
Choice D: While it’s important to reassure the toddler that they are still loved and important, this statement might unintentionally increase anxiety or make the toddler feel less valued. Instead, the nurse should encourage a positive approach, where the toddler can learn how to be a helper and feel involved in the care of the newborn. It’s essential to focus on inclusivity rather than highlighting potential feelings of neglect.
A nurse is caring for a newborn who is 6 hours old and has a bedside glucometer reading of 65 mg/dL. The newborn's mother has type 2 diabetes mellitus.
Which of the following actions should the nurse take?
A. Feed the newborn immediately.
A bedside glucometer reading of 65 mg/dL is within the normal range for a newborn who is 6 hours old. Feeding the newborn can help maintain their blood glucose level.
B. Administer 50 mL of dextrose solution IV.
Choice B is not an answer because administering 50 mL of dextrose solution IV is not necessary for a newborn with a normal blood glucose level.
C. Reassess the blood glucose level prior to the next feeding.
Choice C is not an answer because reassessing the blood glucose level prior to the next feeding is not necessary for a newborn with a normal blood glucose level.
D. Obtain a blood sample for a serum glucose level.
Choice D is not an answer because obtaining a blood sample for a serum glucose level is not necessary for a newborn with a normal blood glucose level.
Full Explanation
A bedside glucometer reading of 65 mg/dL is within the normal range for a newborn who is 6 hours old.
Feeding the newborn can help maintain their blood glucose level.
Choice B is not an answer because administering 50 mL of dextrose solution IV is not necessary for a newborn with a normal blood glucose level.
Choice C is not an answer because reassessing the blood glucose level prior to the next feeding is not necessary for a newborn with a normal blood glucose level.
Choice D is not an answer because obtaining a blood sample for a serum glucose
level is not necessary for a newborn with a normal blood glucose level.
A nurse is admitting a client to the birthing unit who reports her contractions started 1 hour ago. The nurse determines the client is 80% effaced and 8 cm dilated.
The nurse realizes that the client is at risk for which of the following conditions?
A. Ectopic pregnancy.
Choice A is not an answer because ectopic pregnancy occurs when a fertilized egg implants outside of the uterus and is not a risk for a client who is in active labor.
B. Postpartum hemorrhage.
A client who is 80% effaced and 8 cm dilated is in active labor and at risk for postpartum hemorrhage.
C. Incompetent cervix.
Choice C is not an answer because an incompetent cervix refers to a cervix that dilates prematurely during pregnancy and is not a risk for a client who is in active labor.
D. Hyperemesis gravidarum.
Choice D is not an answer because hyperemesis gravidarum refers to severe nausea and vomiting during pregnancy and is not a risk for a client who is in active labor.
Full Explanation
A client who is 80% effaced and 8 cm dilated is in active labor and at risk for postpartum hemorrhage.
Choice A is not an answer because ectopic pregnancy occurs when a fertilized egg implants outside of the uterus and is not a risk for a client who is in active labor.
Choice C is not an answer because an incompetent cervix refers to a cervix that dilates prematurely during pregnancy and is not a risk for a client who is in active labor.
Choice D is not an answer because hyperemesis gravidarum refers to severe nausea and vomiting during pregnancy and is not a risk for a client who is in active labor.