Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse recognizes the client is in the dependent, taking in phase of maternal postpartum adjustment.
Which of the following findings should the nurse expect during this phase?.
A. Focus on the family unit and its members.
Focus on the family unit and its members is more characteristic of the “letting-go” phase.
B. Expressions of excitement.
Expressions of excitement are common in the dependent, taking in phase as the mother is focused on her own needs and the experience of childbirth.
C. Eagerness to learn newborn care skills.
Eagerness to learn newborn care skills is more characteristic of the “taking-hold” phase.
D. Lack of appetite.
Lack of appetite is not a typical characteristic of the dependent, taking in phase.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Custom 2023 Fall NPRO 1100 Proctored Exam 3. Take the full exam now
Full Explanation
The correct answer is choice B.
Choice A rationale:
Focus on the family unit and its members is more characteristic of the “letting-go” phase.
Choice B rationale:
Expressions of excitement are common in the dependent, taking in phase as the mother is focused on her own needs and the experience of childbirth.
Choice C rationale:
Eagerness to learn newborn care skills is more characteristic of the “taking-hold” phase.
Choice D rationale:
Lack of appetite is not a typical characteristic of the dependent, taking in phase.
Similar Questions
Utilize the GTPAL system to classify a woman who is currently 18 weeks pregnant.
This is her 4th pregnancy.
She gave birth to one baby vaginally at 26 weeks who died, experienced a miscarriage, and has one living child who was delivered at 38 weeks gestation.
A. 4, 1, 1, 1.
The GTPAL system stands for Gravida, Term, Preterm, Abortions, and Living children. In this case, the woman has been pregnant 4 times (Gravida 4), has had one term birth (Term 1), one preterm birth (Preterm 1), one abortion/miscarriage (Abortions 1), and one living child (Living 1). Therefore, the correct classification is 4, 1, 1, 1, 1.
B. 3, 2, 1.
This choice incorrectly classifies the number of pregnancies (Gravida should be 4, not 3) and does not account for the preterm birth or the number of living children.
C. 4, 2, 2, 1, 1.
This choice overcounts the number of term births and living children.
D. 3, 2, 1, 1, 1.
This choice incorrectly classifies the number of pregnancies (Gravida should be 4, not 3) and overcounts the number of living children.
Full Explanation
The correct answer is choice A.
Choice A rationale:
The GTPAL system stands for Gravida, Term, Preterm, Abortions, and Living children. In this case, the woman has been pregnant 4 times (Gravida 4), has had one term birth (Term 1), one preterm birth (Preterm 1), one abortion/miscarriage (Abortions 1), and one living child (Living 1). Therefore, the correct classification is 4, 1, 1, 1, 1.
Choice B rationale:
This choice incorrectly classifies the number of pregnancies (Gravida should be 4, not 3) and does not account for the preterm birth or the number of living children.
Choice C rationale:
This choice overcounts the number of term births and living children.
Choice D rationale:
This choice incorrectly classifies the number of pregnancies (Gravida should be 4, not 3) and overcounts the number of living children.
A nurse is caring for a client who gave birth 2 hr ago.
The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?.
A. Evaluate the firmness of the uterus (fundus).
Evaluating the firmness of the uterus (fundus) is the first action the nurse should take when a client’s blood pressure drops postpartum. A soft or “boggy” uterus can indicate uterine atony, a leading cause of postpartum hemorrhage, which can lead to hypotension.
B. Obtain a type and crossmatch.
Obtaining a type and crossmatch is important if the client needs a blood transfusion, but it is not the first action the nurse should take.
C. Administer oxytocin infusion.
Administering oxytocin infusion can help contract the uterus and control bleeding, but the nurse should first assess the uterus.
D. Initiate oxygen therapy by nonrebreather mask.
Initiating oxygen therapy can help if the client is hypoxic, but the nurse should first assess the uterus.
Full Explanation
The correct answer is choice A.
Choice A rationale:
Evaluating the firmness of the uterus (fundus) is the first action the nurse should take when a client’s blood pressure drops postpartum. A soft or “boggy” uterus can indicate uterine atony, a leading cause of postpartum hemorrhage, which can lead to hypotension.
Choice B rationale:
Obtaining a type and crossmatch is important if the client needs a blood transfusion, but it is not the first action the nurse should take.
Choice C rationale:
Administering oxytocin infusion can help contract the uterus and control bleeding, but the nurse should first assess the uterus.
Choice D rationale:
Initiating oxygen therapy can help if the client is hypoxic, but the nurse should first assess the uterus.
The nurse is preparing a teaching plan for a pregnant woman about the signs and symptoms to be reported immediately to her health care provider.
Which signs and symptoms would the nurse include? Select all that apply.
A. Nausea with vomiting during the first trimester.
Nausea with vomiting during the first trimester is a common symptom of pregnancy and does not need to be reported immediately to the health care provider.
B. Sudden leakage of fluid during the second trimester.
Sudden leakage of fluid during the second trimester could indicate premature rupture of membranes, which can lead to infection and preterm labor. This should be reported immediately.
C. Urinary frequency in the third trimester.
Urinary frequency in the third trimester is a common symptom of pregnancy due to the growing uterus putting pressure on the bladder.
D. Backache during the second trimester.
Backache during the second trimester is a common symptom of pregnancy as the body adjusts to the growing uterus.
E. Lower abdominal pain with shoulder pain in the first trimester.
Lower abdominal pain with shoulder pain in the first trimester could indicate an ectopic pregnancy, which is a medical emergency and should be reported immediately.
F. Headache with visual changes in the third trimester.
Headache with visual changes in the third trimester could indicate preeclampsia, a serious condition that can lead to seizures, stroke, and other complications. This should be reported immediately.
Full Explanation
The correct answers are choices B, E, and F.
Choice A rationale:
Nausea with vomiting during the first trimester is a common symptom of pregnancy and does not need to be reported immediately to the health care provider.
Choice B rationale:
Sudden leakage of fluid during the second trimester could indicate premature rupture of membranes, which can lead to infection and preterm labor. This should be reported immediately.
Choice C rationale:
Urinary frequency in the third trimester is a common symptom of pregnancy due to the growing uterus putting pressure on the bladder.
Choice D rationale:
Backache during the second trimester is a common symptom of pregnancy as the body adjusts to the growing uterus.
Choice E rationale:
Lower abdominal pain with shoulder pain in the first trimester could indicate an ectopic pregnancy, which is a medical emergency and should be reported immediately.
Choice F rationale:
Headache with visual changes in the third trimester could indicate preeclampsia, a serious condition that can lead to seizures, stroke, and other complications. This should be reported immediately.