Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a newborn whose mother had a primary cytomegalovirus (CMV) infection during pregnancy. The newborn acquired CMV transplacentally. Which of the following findings should the nurse expect the newborn to exhibit?
A. Cataracts
Cataracts are not a common finding in newborns with congenital CMV infection. Cataracts are more commonly associated with other congenital infections like rubella, toxoplasmosis, and herpes simplex virus (HSV).
B. Hearing loss.
Hearing loss is one of the most common manifestations of congenital CMV infection. Up to 40-58% of infants with symptomatic congenital CMV infection develop sensorineural hearing loss, which can be unilateral or bilateral, and progressive over time.
C. Macrosomia
Macrosomia, or large birth size, is not a typical finding in congenital CMV infection. In fact, infants with symptomatic congenital CMV infection are more likely to be small for gestational age or have intrauterine growth restriction.
D. Urinary tract infection (UTI)
Urinary tract infection (UTI) is not a common presentation of congenital CMV infection. CMV can cause inclusion bodies in the urine, but overt UTI is not a typical finding. More common manifestations include petechiae, hepatosplenomegaly, jaundice, and central nervous system involvement.
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 **b. Hearing loss**.
Choice A rationale:
Cataracts are not a common finding in newborns with congenital CMV infection. Cataracts are more commonly associated with other congenital infections like rubella, toxoplasmosis, and herpes simplex virus (HSV).
Choice B rationale:
Hearing loss is one of the most common manifestations of congenital CMV infection. Up to 40-58% of infants with symptomatic congenital CMV infection develop sensorineural hearing loss, which can be unilateral or bilateral, and progressive over time.
Choice C rationale:
Macrosomia, or large birth size, is not a typical finding in congenital CMV infection. In fact, infants with symptomatic congenital CMV infection are more likely to be small for gestational age or have intrauterine growth restriction.
Choice D rationale:
Urinary tract infection (UTI) is not a common presentation of congenital CMV infection. CMV can cause inclusion bodies in the urine, but overt UTI is not a typical finding. More common manifestations include petechiae, hepatosplenomegaly, jaundice, and central nervous system involvement.
Similar Questions
A nurse is caring for a client who is receiving oxytocin for induction of labor and notes late decelerations of the fetal heart rate on the monitor tracing. Which of the following actions should the nurse take?
A. Decrease maintenance IV solution infusion rate.
Decreasing the maintenance IV solution infusion rate is not the appropriate action for addressing late decelerations of the fetal heart rate. Late decelerations are a concerning sign during labor, indicating possible fetal distress. This can be caused by inadequate oxygenation of the fetus, and reducing IV fluids would not directly address this issue.
B. Place the client in a lateral position.
Placing the client in a lateral (side-lying) position is the correct action when late decelerations are observed. This position helps to improve uteroplacental blood flow and can relieve pressure on the inferior vena cava, thus increasing oxygen supply to the fetus.
C. Administer oxygen via face mask at 2 L/min.
Administering oxygen via face mask at 2 L/min is not the priority action in response to late decelerations. While oxygen may be beneficial in certain situations, it is not the initial intervention for addressing fetal heart rate decelerations.
D. Administer misoprostol 25 mcg vaginally.
Administering misoprostol 25 mcg vaginally is not appropriate for addressing late decelerations. Misoprostol is a medication used for cervical ripening and induction of labor, but it does not directly address fetal heart rate changes.
Full Explanation
Choice A rationale:
Decreasing the maintenance IV solution infusion rate is not the appropriate action for addressing late decelerations of the fetal heart rate. Late decelerations are a concerning sign during labor, indicating possible fetal distress. This can be caused by inadequate oxygenation of the fetus, and reducing IV fluids would not directly address this issue.
Choice B rationale:
Placing the client in a lateral (side-lying) position is the correct action when late decelerations are observed. This position helps to improve uteroplacental blood flow and can relieve pressure on the inferior vena cava, thus increasing oxygen supply to the fetus.
Choice C rationale:
Administering oxygen via face mask at 2 L/min is not the priority action in response to late decelerations. While oxygen may be beneficial in certain situations, it is not the initial intervention for addressing fetal heart rate decelerations.
Choice D rationale:
Administering misoprostol 25 mcg vaginally is not appropriate for addressing late decelerations. Misoprostol is a medication used for cervical ripening and induction of labor, but it does not directly address fetal heart rate changes.
A nurse on an antepartum unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first?
A. A client who is at 34 weeks of gestation and is experiencing epigastric pain and headache.
The nurse should assess this client first as they are at 34 weeks of gestation and experiencing epigastric pain and headache. These symptoms could be indicative of preeclampsia, a serious pregnancy complication characterized by high blood pressure and organ damage. Preeclampsia requires immediate assessment and intervention to prevent further complications.
B. A client who is at 12 weeks of gestation and is experiencing nausea and vomiting.
Nausea and vomiting are common symptoms during the first trimester of pregnancy, and at 12 weeks of gestation, it is less likely to be a critical issue compared to potential preeclampsia.
C. A client who is at 38 weeks of gestation and is experiencing painful urination.
Painful urination may indicate a urinary tract infection, which can be important to assess and treat, but it is not as urgent as potential signs of preeclampsia in a client at 34 weeks of gestation.
D. A client who is at 39 weeks of gestation and is experiencing cramping and spotting.
Cramping and spotting can be normal signs of impending labor, especially at 39 weeks of gestation. While it's important to assess this client, it is not the priority over potential preeclampsia in a client at 34 weeks of gestation with symptoms of epigastric pain and headache.
Full Explanation
Choice A rationale:
The nurse should assess this client first as they are at 34 weeks of gestation and experiencing epigastric pain and headache. These symptoms could be indicative of preeclampsia, a serious pregnancy complication characterized by high blood pressure and organ damage. Preeclampsia requires immediate assessment and intervention to prevent further complications.
Choice B rationale:
Nausea and vomiting are common symptoms during the first trimester of pregnancy, and at 12 weeks of gestation, it is less likely to be a critical issue compared to potential preeclampsia.
Choice C rationale:
Painful urination may indicate a urinary tract infection, which can be important to assess and treat, but it is not as urgent as potential signs of preeclampsia in a client at 34 weeks of gestation.
Choice D rationale:
Cramping and spotting can be normal signs of impending labor, especially at 39 weeks of gestation. While it's important to assess this client, it is not the priority over potential preeclampsia in a client at 34 weeks of gestation with symptoms of epigastric pain and headache.
A nurse is providing prenatal teaching to a client who practices a vegan diet and is trying to increase her intake of vitamin B12. Which of the following foods should the nurse recommend?
A. Fresh citrus fruits.
Fresh citrus fruits are not a good source of vitamin B12. They are rich in vitamin C but do not contain vitamin B12.
B. Brown rice.
Brown rice is not a good source of vitamin B12. While it is a nutritious grain, it does not contain vitamin B12.
C. Raw carrots.
Raw carrots are not a good source of vitamin B12. Carrots provide essential nutrients but do not contain vitamin B12.
D. Fortified soy milk.
Fortified soy milk is the correct choice as it is a suitable option for someone on a vegan diet looking to increase their vitamin B12 intake. Many brands of soy milk are fortified with vitamin B12, making it a reliable source for vegans. Vitamin B12 is essential for nerve function and red blood cell production, making it especially important during pregnancy.
Full Explanation
Choice A rationale:
Fresh citrus fruits are not a good source of vitamin B12. They are rich in vitamin C but do not contain vitamin B12.
Choice B rationale:
Brown rice is not a good source of vitamin B12. While it is a nutritious grain, it does not contain vitamin B12.
Choice C rationale:
Raw carrots are not a good source of vitamin B12. Carrots provide essential nutrients but do not contain vitamin B12.
Choice D rationale:
Fortified soy milk is the correct choice as it is a suitable option for someone on a vegan diet looking to increase their vitamin B12 intake. Many brands of soy milk are fortified with vitamin B12, making it a reliable source for vegans. Vitamin B12 is essential for nerve function and red blood cell production, making it especially important during pregnancy.