Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who experienced a vaginal delivery 16 hr ago. When palpating the client’s abdomen, at which of the following positions should the nurse expect to find the uterine fundus?
A. At the level of the umbilicus
The uterine fundus is expected to be at the level of the umbilicus after delivery and descends approximately one fingerbreadth (or 1 cm) per day after delivery.
B. 2 cm above the umbilicus
The uterine fundus would be too high for this time frame.
C. One fingerbreadth above the symphysis pubis
The fundus should reach the level of the symphysis pubis by 10 days postpartum.
D. To the right of the umbilicus
The uterine fundus should not be palpated to the right of the umbilicus; it should be midline or slightly to the right. A lateral displacement of the fundus may indicate a full bladder, which can interfere with uterine contraction and increase the risk of bleeding.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Maternal Newborn Proctored Exam 3 Reno 2 2020. Take the full exam now
Full Explanation
A. The uterine fundus is expected to be at the level of the umbilicus after delivery and descends approximately one fingerbreadth (or 1 cm) per day after delivery.
B. The uterine fundus would be too high for this time frame.
C. The fundus should reach the level of the symphysis pubis by 10 days postpartum.
D. The uterine fundus should not be palpated to the right of the umbilicus; it should be midline or slightly to the right. A lateral displacement of the fundus may indicate a full bladder, which can interfere with uterine contraction and increase the risk of bleeding.
Similar Questions
A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago by cesarean section is found to have moist lung sounds. What is the best interpretation of these data?
A. The nurse should immediately notify the pediatrician for this emergency situation
Moist lung sounds in this context are not indicative of an emergency situation requiring immediate notification of the pediatrician.
B. The lungs of a baby delivered by cesarean section may sound moist during the first 24 hours after childbirth
Moist lung sounds in a baby born by cesarean section are common and may be due to retained lung fluid, often resolving within the first 24 hours after birth. This is because the baby does not experience the same compression of the chest during delivery as a baby born vaginally, which helps to expel some of the fluid from the lungs.
C. The neonate must have aspirated surfactant
Aspiration of surfactant is not a common or likely occurrence.
D. If this baby was born vaginally, then a pneumothorax could be indicated
Moist lung sounds are not typically indicative of a pneumothorax, especially in the absence of other signs and symptoms.
Full Explanation
A. Moist lung sounds in this context are not indicative of an emergency situation requiring immediate notification of the pediatrician.
B. Moist lung sounds in a baby born by cesarean section are common and may be due to retained lung fluid, often resolving within the first 24 hours after birth. This is because the baby does not experience the same compression of the chest during delivery as a baby born vaginally, which helps to expel some of the fluid from the lungs.
C. Aspiration of surfactant is not a common or likely occurrence.
D. Moist lung sounds are not typically indicative of a pneumothorax, especially in the absence of other signs and symptoms.
A nurse in a pediatric clinic is caring for a client who is postpartum and asks the nurse what to do when her newborn cries persistently. Which of the following strategies are appropriate for the nurse to teach the new mother about her infant?
A. Allow the newborn to continue crying.
Allowing the newborn to continue crying without attempting to soothe the baby is not an appropriate strategy for responsive parenting.
B. Keep the newborn in the center of a large crib.
Keeping the newborn in the center of a large crib without attending to the baby's needs is not responsive caregiving.
C. Carry the newborn evert time he/she cries.
Carrying the newborn every time he/she cries may not be practical or necessary, and it's important to encourage safe sleep practices.
D. Swaddle the newborn in a receiving blanket.
Swaddling the newborn in a receiving blanket can provide comfort and a sense of security, promoting sleep and reducing crying.
Full Explanation
A. Allowing the newborn to continue crying without attempting to soothe the baby is not an appropriate strategy for responsive parenting.
B. Keeping the newborn in the center of a large crib without attending to the baby's needs is not responsive caregiving.
C. Carrying the newborn every time he/she cries may not be practical or necessary, and it's important to encourage safe sleep practices.
D. Swaddling the newborn in a receiving blanket can provide comfort and a sense of security, promoting sleep and reducing crying.
A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn’s maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make?
A. “Look at how she looks as you when you speak. That’s a good sign.”
While visual attention to the speaker is a positive sign, routine hearing screenings provide a more accurate assessment of hearing.
B. “We do routine hearing screenings on newborns. You’ll know the results before you leave the hospital.”
Routine hearing screenings are conducted on newborns to identify hearing issues early, allowing for intervention if necessary.
C. “There is no need to worry about that. Most forms of hearing loss are not inherited.”
While most forms of hearing loss may not be inherited, it's important to assess the newborn's hearing through appropriate screenings.
D. “The best way to determine if your baby can hear is to clap your hands loudly and see if she startles.”
Startle reflex is not a reliable indicator of hearing ability, and routine screenings provide more accurate information.
Full Explanation
A. While visual attention to the speaker is a positive sign, routine hearing screenings provide a more accurate assessment of hearing.
B. Routine hearing screenings are conducted on newborns to identify hearing issues early, allowing for intervention if necessary.
C. While most forms of hearing loss may not be inherited, it's important to assess the newborn's hearing through appropriate screenings.
D. Startle reflex is not a reliable indicator of hearing ability, and routine screenings provide more accurate information.