Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a newborn who has Trisomy 21 (Down’s Syndrome). Which of the following are common characteristics? (Select all that apply.)
A. Transverse palmar creases
Transverse palmar creases, also known as a single palmar crease, are a common characteristic of Down syndrome. This feature is present in many individuals with the condition.
B. Muscular hypertonicity
Muscular hypertonicity (increased muscle tone) is not typical in Down syndrome. Instead, individuals with Down syndrome often have hypotonia (decreased muscle tone).
C. Protruding tongue
A protruding tongue is a common characteristic of Down syndrome. This is due to a combination of factors, including a small oral cavity and low muscle tone.
D. Large ears
Large ears are not a typical feature of Down syndrome. Individuals with Down syndrome often have small or unusually shaped ears.
E. Low birth weight
Low birth weight is not specifically associated with Down syndrome. While some infants with Down syndrome may have low birth weight, it is not a defining characteristic.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Nur 232 Maternity Final Proctored Exam Sp24. Take the full exam now
Full Explanation
The correct answers are A. Transverse palmar creases and C. Protruding tongue.
Choice A rationale:
Transverse palmar creases, also known as a single palmar crease, are a common characteristic of Down syndrome. This feature is present in many individuals with the condition.
Choice B rationale:
Muscular hypertonicity (increased muscle tone) is not typical in Down syndrome. Instead, individuals with Down syndrome often have hypotonia (decreased muscle tone).
Choice C rationale:
A protruding tongue is a common characteristic of Down syndrome. This is due to a combination of factors, including a small oral cavity and low muscle tone.
Choice D rationale:
Large ears are not a typical feature of Down syndrome. Individuals with Down syndrome often have small or unusually shaped ears.
Choice E rationale:
Low birth weight is not specifically associated with Down syndrome. While some infants with Down syndrome may have low birth weight, it is not a defining characteristic.
Similar Questions
A nurse is caring for a client who is about to undergo an amniotomy. What is the priority nursing action following this procedure?
A. Assess the fetal heart rate pattern.
Assessing the fetal heart rate pattern is the priority nursing action following an amniotomy. This allows the nurse to monitor for signs of fetal distress, which can occur if the umbilical cord becomes compressed or prolapses as a result of the procedure.
B. Observe the color and consistency of fluid.
Observing the color and consistency of the fluid can provide information about the well-being of the fetus, but it is not the priority action following an amniotomy.
C. Assess the client’s temperature.
Assessing the client’s temperature is important to monitor for signs of infection, but it is not the priority action following an amniotomy.
D. Evaluate the client for the presence of chills and increased uterine tenderness using palpation.
Evaluating the client for the presence of chills and increased uterine tenderness using palpation can help identify complications such as infection or uterine rupture, but it is not the priority action following an amniotomy.
Full Explanation
Choice A rationale
Assessing the fetal heart rate pattern is the priority nursing action following an amniotomy. This allows the nurse to monitor for signs of fetal distress, which can occur if the umbilical cord becomes compressed or prolapses as a result of the procedure.
Choice B rationale
Observing the color and consistency of the fluid can provide information about the well-being of the fetus, but it is not the priority action following an amniotomy.
Choice C rationale
Assessing the client’s temperature is important to monitor for signs of infection, but it is not the priority action following an amniotomy.
Choice D rationale
Evaluating the client for the presence of chills and increased uterine tenderness using palpation can help identify complications such as infection or uterine rupture, but it is not the priority action following an amniotomy.
A nurse is performing a physical examination of a client who is 1 day postpartum. Which finding requires immediate attention?
A. Displaced fundus from the midline.
A displaced fundus from the midline in a postpartum client can indicate a full bladder, which can interfere with uterine contraction and lead to excessive bleeding. This is a serious condition that requires immediate attention to prevent further complications such as postpartum hemorrhage.
B. Fundal height below the umbilicus.
A fundal height below the umbilicus is a normal finding in a postpartum client. The uterus normally decreases in size after delivery, and the fundus is typically located at or below the level of the umbilicus within 24 hours postpartum.
C. Increased urine output.
Increased urine output is a normal physiological response after delivery. During pregnancy, there is an increase in blood volume that leads to increased fluid in the body. After delivery, the body eliminates this extra fluid through increased urine output.
D. Decreased urge to void.
A decreased urge to void can be a normal finding in the immediate postpartum period due to decreased bladder sensitivity from the trauma of childbirth or epidural anesthesia. However, it’s important for the nurse to monitor this because urinary retention can lead to bladder distention and uterine atony, increasing the risk of postpartum hemorrhage.
Full Explanation
Choice A rationale
A displaced fundus from the midline in a postpartum client can indicate a full bladder, which can interfere with uterine contraction and lead to excessive bleeding. This is a serious
condition that requires immediate attention to prevent further complications such as postpartum hemorrhage.
Choice B rationale
A fundal height below the umbilicus is a normal finding in a postpartum client. The uterus normally decreases in size after delivery, and the fundus is typically located at or below the level of the umbilicus within 24 hours postpartum.
Choice C rationale
Increased urine output is a normal physiological response after delivery. During pregnancy, there is an increase in blood volume that leads to increased fluid in the body. After delivery, the body eliminates this extra fluid through increased urine output.
Choice D rationale
A decreased urge to void can be a normal finding in the immediate postpartum period due to decreased bladder sensitivity from the trauma of childbirth or epidural anesthesia. However, it’s important for the nurse to monitor this because urinary retention can lead to bladder distention and uterine atony, increasing the risk of postpartum hemorrhage.
A nurse on the labor and delivery unit is caring for a patient undergoing labor induction with oxytocin administered through a secondary IV line.
Uterine contractions occur every 2 minutes, last 90 seconds, and are strong to palpation.
The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over.
What action should the nurse take?
A. Slow the client’s rate of breathing.
Slowing the client’s rate of breathing would not directly address the issue of strong, frequent contractions and uniform decelerations of the fetal heart rate. These symptoms suggest uterine hyperstimulation, which can compromise fetal oxygenation.
B. Increase the rate of infusion of the IV oxytocin.
Increasing the rate of infusion of the IV oxytocin would likely exacerbate the problem, as oxytocin can cause uterine hyperstimulation, leading to reduced fetal oxygen supply.
C. Discontinue the infusion of the IV oxytocin.
Discontinuing the infusion of the IV oxytocin is the appropriate action. The pattern of contractions and fetal heart rate decelerations suggest uterine hyperstimulation, which can be caused by excessive oxytocin. Stopping the oxytocin infusion can help to normalize the contraction pattern and improve fetal oxygenation.
D. Decrease the rate of infusion of the maintenance IV solution.
Decreasing the rate of infusion of the maintenance IV solution would not directly address the issue of uterine hyperstimulation and fetal heart rate decelerations.
Full Explanation
Choice A rationale
Slowing the client’s rate of breathing would not directly address the issue of strong, frequent contractions and uniform decelerations of the fetal heart rate. These symptoms suggest uterine hyperstimulation, which can compromise fetal oxygenation.
Choice B rationale
Increasing the rate of infusion of the IV oxytocin would likely exacerbate the problem, as oxytocin can cause uterine hyperstimulation, leading to reduced fetal oxygen supply.
Choice C rationale
Discontinuing the infusion of the IV oxytocin is the appropriate action. The pattern of contractions and fetal heart rate decelerations suggest uterine hyperstimulation, which can be caused by excessive oxytocin. Stopping the oxytocin infusion can help to normalize the contraction pattern and improve fetal oxygenation.
Choice D rationale
Decreasing the rate of infusion of the maintenance IV solution would not directly address the issue of uterine hyperstimulation and fetal heart rate decelerations.