Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a newborn who is 4 hr old. Which of the following findings should the nurse identify as the priority to report to the provider?
A. Bluish discoloration of the hands and feet.
Bluish discoloration of the hands and feet (acrocyanosis) is common in newborns and usually resolves within the first few days of life. It is not typically a priority unless it persists or is accompanied by other signs of distress.
B. Overlapping of the cranial bones.
Overlapping of the cranial bones (craniosynostosis) requires monitoring but is not an immediate priority unless there are signs of increased intracranial pressure.
C. Forward and lateral positioning of the ears.
Forward and lateral positioning of the ears can be indicative of certain genetic conditions, such as Down syndrome. This finding is significant as it can signal the need for further evaluation and intervention to address any associated health concerns.
D. Small, distended white sebaceous glands on the face.
Small, distended white sebaceous glands on the face, known as milia, are common in newborns and are not a priority finding to report to the provider. They are benign and usually resolve on their own without treatment.
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 Choice C.
Choice A rationale: Bluish discoloration of the hands and feet (acrocyanosis) is common in newborns and usually resolves within the first few days of life. It is not typically a priority unless it persists or is accompanied by other signs of distress.
Choice B rationale: Overlapping of the cranial bones (craniosynostosis) requires monitoring but is not an immediate priority unless there are signs of increased intracranial pressure.
Choice C rationale: Forward and lateral positioning of the ears can be indicative of certain genetic conditions, such as Down syndrome. This finding is significant as it can signal the need for further evaluation and intervention to address any associated health concerns.
Choice D rationale: Small, distended white sebaceous glands on the face (milia) are common in newborns and resolve on their own without intervention.
Similar Questions
A nurse is caring for a client who is in active labor and is receiving oxytocin via IV infusion. The nurse has applied an internal fetal heart monitor and recognizes an early deceleration of the fetal heart rate tracing. Which of the following actions should the nurse take?
A. Continue to monitor the client.
Early decelerations are typically benign and are caused by fetal head compression during contractions. They usually do not require any specific intervention other than continued monitoring to ensure they remain early decelerations and do not progress to more concerning patterns.
B. Discontinue the oxytocin.
Discontinuing oxytocin is not necessary for early decelerations, as they are not indicative of fetal distress. Oxytocin would be discontinued if there were signs of more severe decelerations or other complications.
C. Assist the client to lay on her right side.
Assisting the client to lay on her right side is not specifically required for early decelerations. This position change is more commonly used for variable or late decelerations to improve uteroplacental blood flow.
D. Administer oxygen at 8 L/min per mask.
Administering oxygen at 8 L/min per mask is not needed for early decelerations. Oxygen is typically reserved for situations where there is evidence of fetal hypoxia or distress.
Full Explanation
The correct answer is choice A. Continue to monitor the client.
Choice A rationale:
Early decelerations are typically benign and are caused by fetal head compression during contractions. They usually do not require any specific intervention other than continued monitoring to ensure they remain early decelerations and do not progress to more concerning patterns.
Choice B rationale:
Discontinuing oxytocin is not necessary for early decelerations, as they are not indicative of fetal distress. Oxytocin would be discontinued if there were signs of more severe decelerations or other complications.
Choice C rationale:
Assisting the client to lay on her right side is not specifically required for early decelerations. This position change is more commonly used for variable or late decelerations to improve uteroplacental blood flow.
Choice D rationale:
Administering oxygen at 8 L/min per mask is not needed for early decelerations. Oxygen is typically reserved for situations where there is evidence of fetal hypoxia or distress.
A nurse is admitting a client who is at 38 weeks of gestation following a spontaneous rupture of membranes. The nurse performs a vaginal examination and palpates the umbilical cord. Which of the following actions should the nurse take?
A. Request that the provider insert an intrauterine pressure catheter.
Requesting that the provider insert an intrauterine pressure catheter is not the immediate action the nurse should take when the umbilical cord is palpated during a vaginal examination. The priority is to relieve pressure on the cord and improve fetal oxygenation.
B. Exert continuous upward pressure on the presenting part.
Exerting continuous upward pressure on the presenting part is the correct action when the nurse palpates the umbilical cord during a vaginal examination. This maneuver, called "vaginal elevation,”. helps lift the presenting part off the umbilical cord, reducing the risk of cord compression and fetal distress until the provider can take further action.
C. Initiate oxytocin via continuous IV infusion.
Initiating oxytocin via continuous IV infusion is not appropriate when the umbilical cord is palpated during a vaginal examination. Oxytocin can cause uterine contractions, potentially further compromising the cord and fetus.
D. Place the client in the left-lateral position.
Placing the client in the left-lateral position is not the best immediate action for cord palpation. While left-lateral position is useful for relieving pressure on the vena cava in cases of supine hypotensive syndrome, the priority here is to relieve cord compression, and upward pressure on the presenting part is more effective.
Full Explanation
Choice A rationale:
Requesting that the provider insert an intrauterine pressure catheter is not the immediate action the nurse should take when the umbilical cord is palpated during a vaginal examination. The priority is to relieve pressure on the cord and improve fetal oxygenation.
Choice B rationale:
Exerting continuous upward pressure on the presenting part is the correct action when the nurse palpates the umbilical cord during a vaginal examination. This manoeuvre is called "vaginal elevation,”. helps lift the presenting part off the umbilical cord, reducing the risk of cord compression and fetal distress until the provider can take further action.
Choice C rationale:
Initiating oxytocin via continuous IV infusion is not appropriate when the umbilical cord is palpated during a vaginal examination. Oxytocin can cause uterine contractions, potentially further compromising the cord and fetus.
Choice D rationale:
Placing the client in the left-lateral position is not the best immediate action for cord palpation. While the left-lateral position is useful for relieving pressure on the vena cava in cases of supine hypotensive syndrome, the priority here is to relieve cord compression, and upward pressure on the presenting part is more effective.
A nurse is reviewing the medical record for a client who is receiving treatment for gestational diabetes mellitus. Which of the following medications should the nurse expect to administer?
A. Levothyroxine.
Levothyroxine is not a medication used to treat gestational diabetes mellitus. Levothyroxine is a synthetic thyroid hormone used to treat hypothyroidism, which is a different medical condition.
B. Nifedipine.
Nifedipine is a calcium channel blocker primarily used to manage hypertension and angina. It is not indicated for the treatment of gestational diabetes mellitus.
C. Chlorpromazine.
Chlorpromazine is an antipsychotic medication used to treat conditions like schizophrenia and bipolar disorder. It has no role in the treatment of gestational diabetes mellitus.
D. Glyburide.
Glyburide is the correct medication to expect for administering to a client with gestational diabetes mellitus. Glyburide is an oral antidiabetic agent that helps lower blood glucose levels by increasing insulin secretion from the pancreas. It is often used when dietary and lifestyle modifications are not sufficient in managing gestational diabetes. However, it is essential to follow healthcare provider guidelines and closely monitor the client's blood glucose levels while on this medication. In some cases, insulin may be required if glyburide alone is inadequate in controlling blood sugar levels.
Full Explanation
Choice A rationale:
Levothyroxine is not a medication used to treat gestational diabetes mellitus. Levothyroxine is a synthetic thyroid hormone used to treat hypothyroidism, which is a different medical condition.
Choice B rationale:
Nifedipine is a calcium channel blocker primarily used to manage hypertension and angina. It is not indicated for the treatment of gestational diabetes mellitus.
Choice C rationale:
Chlorpromazine is an antipsychotic medication used to treat conditions like schizophrenia and bipolar disorder. It has no role in the treatment of gestational diabetes mellitus.
Choice D rationale:
Glyburide is the correct medication to expect for administering to a client with gestational diabetes mellitus. Glyburide is an oral antidiabetic agent that helps lower blood glucose levels by increasing insulin secretion from the pancreas. It is often used when dietary and lifestyle modifications are not sufficient in managing gestational diabetes. However, it is essential to follow healthcare provider guidelines and closely monitor the client's blood glucose levels while on this medication. In some cases, insulin may be required if glyburide alone is inadequate in controlling blood sugar levels.