Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a newborn who was born vaginally with vacuum extractor assistance. The nurse notes swelling over the newborn's head that crosses the suture line. The nurse should identify the swelling as which of the following findings?
A. Nevus flammeus.
Nevus flammeus, also known as a port-wine stain, is a flat, pink, red, or purple mark on the skin present at birth. It is a congenital vascular malformation and does not involve swelling that crosses suture lines.
B. Caput succedaneum.
Caput succedaneum is the correct diagnosis for swelling that crosses suture lines on a newborn's head, typically associated with a prolonged or difficult vaginal delivery, especially with the use of vacuum extraction.
C. Cephalohematoma.
Cephalohematoma is a collection of blood under the periosteum of the cranial bones that does not cross suture lines. It appears soon after birth and is usually caused by birth trauma.
D. Erythema toxicum.
Erythema toxicum is a common rash in newborns, presenting as red patches with small white or yellow pustules. It does not cause swelling over the head that crosses suture lines.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Maternal Newborn Proctored Exam. Take the full exam now
Full Explanation
Choice A reason:
Nevus flammeus, also known as a port-wine stain, is a flat, pink, red, or purple mark on the skin present at birth. It is a congenital vascular malformation and does not involve swelling that crosses suture lines.
Choice B reason:
Caput succedaneum is the correct diagnosis for swelling that crosses suture lines on a newborn's head, typically associated with a prolonged or difficult vaginal delivery, especially with the use of vacuum extraction.
Choice C reason:
Cephalohematoma is a collection of blood under the periosteum of the cranial bones that does not cross suture lines. It appears soon after birth and is usually caused by birth trauma.
Choice D reason:
Erythema toxicum is a common rash in newborns, presenting as red patches with small white or yellow pustules. It does not cause swelling over the head that crosses suture lines.
Similar Questions
A nurse is discussing recommendations for daily nutrient intake during pregnancy with a client who is at 10 weeks of gestation. For which of the following nutrients should the nurse instruct the client to increase intake during pregnancy?
A. Vitamin E.
Vitamin E is important for overall health but does not need to be specifically increased during pregnancy.
B. Vitamin D.
Vitamin D supports calcium absorption, but routine intake is generally sufficient unless a deficiency exists.
C. Fiber.
Fiber intake should be increased during pregnancy to help prevent constipation, which is a common issue due to hormonal changes and slowed gastrointestinal motility.
D. Calcium.
Calcium intake is important, but for many clients, standard dietary recommendations are adequate unless otherwise prescribed.
E. None
None
F. None
None
Full Explanation
A. Vitamin E is important for overall health but does not need to be specifically increased during pregnancy.
B. Vitamin D supports calcium absorption, but routine intake is generally sufficient unless a deficiency exists.
C. Fiber intake should be increased during pregnancy to help prevent constipation, which is a common issue due to hormonal changes and slowed gastrointestinal motility.
D. Calcium intake is important, but for many clients, standard dietary recommendations are adequate unless otherwise prescribed.
A nurse is caring for a client who is at 14 weeks of gestation and has hyperemesis gravidarum. Which of the following medications should the nurse plan to administer?
A. Digoxin.
Digoxin is a cardiac glycoside and is primarily used in the management of certain heart conditions, such as heart failure and atrial fibrillation. It is not indicated for hyperemesis gravidarum, which is severe and persistent vomiting during pregnancy.
B. Calcium gluconate.
Calcium gluconate is a mineral supplement used to treat calcium deficiencies. It is not a standard treatment for hyperemesis gravidarum.
C. Vitamin Bs.
Vitamin Bs (B6 and B12) are commonly used to manage hyperemesis gravidarum. Vitamin B6, also known as pyridoxine, has been shown to alleviate nausea and vomiting during pregnancy. Vitamin B12 may also be administered to help manage symptoms. Both vitamins are safe to use during pregnancy.
D. Propranolol.
Propranolol is a beta-blocker used to treat high blood pressure, heart conditions, and migraines. It is not recommended for managing hyperemesis gravidarum and is generally avoided during pregnancy due to potential risks to the developing fetus.
Full Explanation
Choice A rationale:
Digoxin is a cardiac glycoside and is primarily used in the management of certain heart conditions, such as heart failure and atrial fibrillation. It is not indicated for hyperemesis gravidarum, which is severe and persistent vomiting during pregnancy.
Choice B rationale:
Calcium gluconate is a mineral supplement used to treat calcium deficiencies. It is not a standard treatment for hyperemesis gravidarum.
Choice C rationale:
Vitamin Bs (B6 and B12) are commonly used to manage hyperemesis gravidarum. Vitamin B6, also known as pyridoxine, has been shown to alleviate nausea and vomiting during pregnancy. Vitamin B12 may also be administered to help manage symptoms. Both vitamins are safe to use during pregnancy.
Choice D rationale:
Propranolol is a beta-blocker used to treat high blood pressure, heart conditions, and migraines. It is not recommended for managing hyperemesis gravidarum and is generally avoided during pregnancy due to potential risks to the developing fetus.
A nurse is developing a plan of care for a newborn who has hyperbilirubinemia and a prescription for phototherapy. Which of the following interventions should the nurse include?
A. Check the newborn's temperature every 8 hr.
Checking the newborn's temperature every 8 hours is not directly related to managing hyperbilirubinemia or phototherapy. Monitoring the newborn's temperature is important, but it should be done more frequently, especially during phototherapy, as infants are at risk of developing hypothermia.
B. Apply moisturizing lotion to the newborn's skin every 4 hr.
Applying moisturizing lotion to the newborn's skin every 4 hours is not a necessary intervention for hyperbilirubinemia or phototherapy. While skin care is important for all newborns, it is not a specific intervention for this condition.
C. Give the newborn 1 oz of glucose water every 4 hr.
Giving the newborn 1 oz of glucose water every 4 hours is not an appropriate intervention for hyperbilirubinemia. Glucose water is not a recommended treatment for this condition. Instead, phototherapy helps break down the bilirubin and promote its elimination from the body.
D. Reposition the newborn every 2 to 3 hr.
Repositioning the newborn every 2 to 3 hours is the correct intervention. Repositioning helps ensure even exposure of the baby's skin to the phototherapy lights, maximizing its effectiveness in reducing bilirubin levels. Additionally, repositioning prevents pressure ulcers and promotes comfort for the infant during treatment.
Full Explanation
Choice A rationale:
Checking the newborn's temperature every 8 hours is not directly related to managing hyperbilirubinemia or phototherapy. Monitoring the newborn's temperature is important, but it should be done more frequently, especially during phototherapy, as infants are at risk of developing hypothermia.
Choice B rationale:
Applying moisturizing lotion to the newborn's skin every 4 hours is not a necessary intervention for hyperbilirubinemia or phototherapy. While skin care is important for all newborns, it is not a specific intervention for this condition.
Choice C rationale:
Giving the newborn 1 oz of glucose water every 4 hours is not an appropriate intervention for hyperbilirubinemia. Glucose water is not a recommended treatment for this condition.
Instead, phototherapy helps break down the bilirubin and promote its elimination from the body.
Choice D rationale:
Repositioning the newborn every 2 to 3 hours is the correct intervention. Repositioning helps ensure even exposure of the baby's skin to the phototherapy lights, maximizing its effectiveness in reducing bilirubin levels. Additionally, repositioning prevents pressure ulcers and promotes comfort for the infant during treatment.