Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assisting in the care of a client who had a vaginal birth 2 hours ago. Which of the following actions should the nurse take? (Select all that apply.)
A. Document fundal height
This is a correct action because the nurse should monitor the involution of the uterus by measuring the fundal height and comparing it to the expected level. The fundus should descend about one fingerbreadth (1 cm) per day after delivery and be at the level of the umbilicus immediately after birth.
B. Observe the lochia during palpation of fundus
This is a correct action because the nurse should assess the amount, color, and consistency of the lochia (vaginal discharge) during the fundal massage. The lochia should change from rubra (red) to serosa (pink) to alba (white) over time and not increase in amount or revert to a previous stage.
C. Massage a firm fundus
This is an incorrect action because a firm fundus indicates adequate uterine contraction and involution. Massaging a firm fundus can cause discomfort and bleeding for the client. The nurse should only massage a boggy (soft) fundus to stimulate contraction and prevent hemorrhage.
D. Determine whether the fundus is midline
This is a correct action because the nurse should check if the fundus is deviated to either side, which may indicate a full bladder. A full bladder can interfere with uterine contraction and cause bleeding or infection. The nurse should assist the client to void if the fundus is not midline.
E. Administer terbutaline if the fundus is boggy
This is an incorrect action because terbutaline is a tocolytic drug that relaxes the uterine muscle and inhibits contractions. It is used to stop preterm labor, not to treat postpartum hemorrhage. The nurse should administer oxytocin or other uterotonic drugs if the fundus is boggy and does not respond to massage.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom Maternity Final 23D Proctored Exam. Take the full exam now
Full Explanation
Choice A:
Document fundal height. This is a correct action because the nurse should monitor the involution of the uterus by measuring the fundal height and comparing it to the expected level. The fundus should descend about one fingerbreadth (1 cm) per day after delivery and be at the level of the umbilicus immediately after birth.
Choice B:
Observe the lochia during palpation of the fundus. This is a correct action because the nurse should assess the amount, color, and consistency of the lochia (vaginal discharge) during the fundal massage. The lochia should change from rubra (red) to serosa (pink) to alba (white) over time and not increase in amount or revert to a previous stage.
Choice C:
Massage a firm fundus. This is an incorrect action because a firm fundus indicates adequate uterine contraction and involution. Massaging a firm fundus can cause discomfort and bleeding for the client. The nurse should only massage a boggy (soft) fundus to stimulate contraction and prevent hemorrhage.
Choice D:
Determine whether the fundus is midline. This is a correct action because the nurse should check if the fundus is deviated to either side, which may indicate a full bladder. A full bladder can interfere with uterine contraction and cause bleeding or infection. The nurse should assist the client to void if the fundus is not midline.
Choice E:
Administer terbutaline if the fundus is boggy. This is an incorrect action because terbutaline is a tocolytic drug that relaxes the uterine muscle and inhibits contractions. It is used to stop preterm labor, not to treat postpartum hemorrhage. The nurse should administer oxytocin or other uterotonic drugs if the fundus is boggy and does not respond to massage.
Similar Questions
Forms of exercise appropriate for a pregnant patient are? (Select all that apply.)
A. Swimming
Swimming is one of the best exercises for pregnant women because it provides moderate aerobic conditioning with minimal stress on your joints. It also supports your increased weight and helps you stay cool and comfortable.
B. Scuba diving
Scuba diving is not a safe exercise for pregnant women because it poses a high risk of injury to the baby. The baby has no protection against decompression sickness and gas embolism, which are caused by changes in pressure underwater.
C. Walking
Walking is a great exercise for beginners and can be done throughout pregnancy. It improves your cardiovascular fitness, strengthens your muscles and bones, and helps prevent excessive weight gain and gestational diabetes.
D. Yoga
Yoga can be beneficial for pregnant women as it can improve flexibility, balance, posture, breathing and relaxation. It can also reduce stress, anxiety and back pain. However, some yoga poses may not be suitable for pregnancy, so it is advisable to join a prenatal yoga class or consult a qualified instructor.
E. Snow skiing
Snow skiing is not recommended for pregnant women because it involves a high risk of falling and affecting your balance. Falls can cause damage to your baby or placenta, especially in the second and third trimesters.
Full Explanation
Choice A reason:
Swimming is one of the best exercises for pregnant women because it provides moderate aerobic conditioning with minimal stress on your joints. It also supports your increased weight and helps you stay cool and comfortable.
Choice B reason:
Scuba diving is not a safe exercise for pregnant women because it poses a high risk of injury to the baby. The baby has no protection against decompression sickness and gas embolism, which are caused by changes in pressure underwater.
Choice C reason:
Walking is a great exercise for beginners and can be done throughout pregnancy. It improves your cardiovascular fitness, strengthens your muscles and bones, and helps prevent excessive weight gain and gestational diabetes.
Choice D reason:
Yoga can be beneficial for pregnant women as it can improve flexibility, balance, posture, breathing and relaxation. It can also reduce stress, anxiety and back pain. However, some yoga poses may not be suitable for pregnancy, so it is advisable to join a prenatal yoga class or consult a qualified instructor.
Choice E reason:
Snow skiing is not recommended for pregnant women because it involves a high risk of falling and affecting your balance. Falls can cause damage to your baby or placenta, especially in the second and third trimesters.
A nurse is assisting to collect data for a gestational age assessment on a newborn. Which of the following should the nurse check during a neuromuscular assessment? (Select all that apply.)
A. Heel to ear
Heel to ear is a test that measures the flexibility of the newborn's hip and knee joints. The nurse should gently flex the newborn's hip and knee and bring the foot toward the ear on the same side. The closer the foot is to the ear, the higher the score. This test is part of the neuromuscular assessment for gestational age.
B. Popliteal angle
Popliteal angle is a test that measures the angle of flexion at the knee joint. The nurse should flex the newborn's hip and knee at 90 degrees and then extend the lower leg until resistance is felt. The smaller the angle, the higher the score. This test is also part of the neuromuscular assessment for gestational age.
C. Moro reflex
Moro reflex is a test that evaluates the newborn's startle response. The nurse should hold the newborn in a semi-sitting position and then allow the head to fall back slightly. The newborn should extend and abduct the arms and legs, then flex and adduct them. This test is not part of the neuromuscular assessment for gestational age, but rather a reflex assessment for neurological function.
D. Scarf sign
Scarf sign is a test that measures the flexibility of the newborn's shoulder and elbow joints. The nurse should draw one of the newborn's arms across the chest toward the opposite shoulder. The farther the elbow can be moved across the body, the lower the score. This test is part of the neuromuscular assessment for gestational age.
E. Arm recoil
Arm recoil is a test that measures the degree of flexion at the elbow joint. The nurse should extend both of the newborn's arms for 5 seconds and then release them. The arms should return to a flexed position quickly and fully. The faster and more complete the recoil, the higher the score. This test is part of the neuromuscular assessment for gestational age.
Full Explanation
Choice A reason:
Heel to ear is a test that measures the flexibility of the newborn's hip and knee joints. The nurse should gently flex the newborn's hip and knee and bring the foot toward the ear on the same side. The closer the foot is to the ear, the higher the score. This test is part of the neuromuscular assessment for gestational age.
Choice B reason:
Popliteal angle is a test that measures the angle of flexion at the knee joint. The nurse should flex the newborn's hip and knee at 90 degrees and then extend the lower leg until resistance is felt. The smaller the angle, the higher the score. This test is also part of the neuromuscular assessment for gestational age.
Choice C reason:
Moro reflex is a test that evaluates the newborn's startle response. The nurse should hold the newborn in a semi-sitting position and then allow the head to fall back slightly. The newborn should extend and abduct the arms and legs, then flex and adduct them. This test is not part of the neuromuscular assessment for gestational age, but rather a reflex assessment for neurological function. •
Choice D reason:
Scarf sign is a test that measures the flexibility of the newborn's shoulder and elbow joints. The nurse should draw one of the newborn's arms across the chest toward the opposite shoulder. The farther the elbow can be moved across the body, the lower the score. This test is part of the neuromuscular assessment for gestational age.
Choice E reason:
Arm recoil is a test that measures the degree of flexion at the elbow joint. The nurse should extend both of the newborn's arms for 5 seconds and then release them. The arms should return to a flexed position quickly and fully. The faster and more complete the recoil, the higher the score. This test is part of the neuromuscular assessment for gestational age.
What causes congenital hip dysplasia?
A. Using illicit drugs
Using illicit drugs is not a known cause of congenital hip dysplasia. Illicit drugs may have other harmful effects on the baby, but they do not affect the formation of the hip joint.
B. Unknown
The exact cause of congenital hip dysplasia is not clear. Both genetic and environmental factors seem to play a role in the development of the disorder. Some risk factors include being female, firstborn, breech position, family history, and tight swaddling.
C. Being in nursing school
Being in nursing school is not a cause of congenital hip dysplasia. This is an irrelevant and incorrect choice.
D. Drinking too much.
Drinking too much is not a cause of congenital hip dysplasia. Alcohol consumption during pregnancy may increase the risk of fetal alcohol syndrome and other complications, but it does not affect the formation of the hip joint.
Full Explanation
Choice A reason:
Using illicit drugs is not a known cause of congenital hip dysplasia. Illicit drugs may have other harmful effects on the baby, but they do not affect the formation of the hip joint.
Choice B reason:
Unknown. The exact cause of congenital hip dysplasia is not clear. Both genetic and environmental factors seem to play a role in the development of the disorder. Some risk factors include being female, firstborn, breech position, family history, and tight swaddling.
Choice C reason:
Being in nursing school is not a cause of congenital hip dysplasia. This is an irrelevant and incorrect choice.
Choice D reason:
Drinking too much is not a cause of congenital hip dysplasia. Alcohol consumption during pregnancy may increase the risk of fetal alcohol syndrome and other complications, but it does not affect the formation of the hip joint.