Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has bladder distention following a vaginal birth. Which of the following actions should the nurse take first?
A. Offer the client a sitz bath.
Offering the client a sitz bath may provide some relief, but it does not address the underlying issue of bladder distention. The priority is to address the bladder distention directly.
B. Insert a urinary catheter.
Inserting a urinary catheter is not the first-line intervention for bladder distention after a vaginal birth. Catheterization carries a risk of infection and trauma, so it should only be done if other interventions are not effective.
C. Assist the client to the bathroom.
Assisting the client to the bathroom is the first action the nurse should take. Bladder distention can occur after birth due to the pressure on the bladder during labor and birth. Encouraging the client to empty her bladder will relieve the distention and promote comfort.
D. Pour warm water over the client's perineum.
Pouring warm water over the client's perineum might provide some comfort, but it does not address the bladder distention itself.
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
Choice A rationale:
Offering the client a sitz bath may provide some relief, but it does not address the underlying issue of bladder distention. The priority is to address the bladder distention directly.
Choice B rationale:
Inserting a urinary catheter is not the first-line intervention for bladder distention after vaginal birth. Catheterization carries a risk of infection and trauma, so it should only be done if other interventions are not effective.
Choice C rationale:
Assisting the client to the bathroom is the first action the nurse should take. Bladder distention can occur after birth due to the pressure on the bladder during labour and birth. Encouraging the client to empty her bladder will relieve the distention and promote comfort.
Choice D rationale:
Pouring warm water over the client's perineum might provide some comfort, but it does not address the bladder distention itself.
Similar Questions
A nurse is calculating the estimated date of delivery for a client who reports that the first day of her last menstrual period was August 10. Using Nägele's Rule, which of the following is the client's estimated date of delivery?
A. May 20.
To calculate the estimated date of delivery using Nägele's Rule, subtract three months from the first day of the last menstrual period (August 10), and then add seven days. However, choice A (May 20) is incorrect because it adds eight days instead of seven.
B. May 3.
It does not add seven days to the calculation.
C. May 13.
It adds three days instead of seven to the calculation
D. May 17.
It follows the correct application of Nägele's Rule. Subtracting three months from August 10 gives us May 10, and then adding seven days gives us May 17as the estimated date of delivery.
Full Explanation
Choice A rationale:
To calculate the estimated date of delivery using Nägele's Rule, subtract three months from the first day of the last menstrual period (August 10), and then add seven days. However, choice A (May 20) is incorrect because it adds eight days instead of seven.
Choice B rationale:
It does not add seven days to the calculation.
Choice C rationale:
It adds three days instead of seven to the calculation
Choice D rationale:
It follows the correct application of Nägele's Rule. Subtracting three months from August 10 gives us May 10, and then adding seven days gives us May 17 as the estimated date of delivery.
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan?
A. Apply a thin layer of lotion to the newborn's skin every 4 hr.
The nurse should not apply lotion to the newborn's skin during phototherapy. Phototherapy involves exposing the newborn's skin to light to treat jaundice by breaking down bilirubin. Applying lotion may interfere with the effectiveness of the therapy and may not be recommended as it can make it difficult for the skin to release heat generated during the process.
B. Give the newborn 1 oz of glucose water every 4 hr.
Giving the newborn glucose water every 4 hours is not a necessary action during phototherapy. The primary concern during phototherapy is to treat jaundice, and giving glucose water may not have a direct impact on the effectiveness of the treatment. Additionally, it is important to focus on monitoring the newborn's bilirubin levels and hydration status.
C. Ensure the newborn's eyes are closed beneath the shield.
Ensure the newborn's eyes are closed beneath the shield.
D. Dress the newborn in a thin layer of clothing during therapy.
Dressing the newborn in a thin layer of clothing during phototherapy is not recommended. Phototherapy works best when the newborn's skin is exposed to the light source, and covering the skin with clothing may decrease the effectiveness of the treatment.
Full Explanation
Choice A rationale:
The nurse should not apply lotion to the newborn's skin during phototherapy. Phototherapy involves exposing the newborn's skin to light to treat jaundice by breaking down bilirubin. Applying lotion may interfere with the effectiveness of the therapy and may not be recommended as it can make it difficult for the skin to release heat generated during the process.
Choice B rationale:
Giving the newborn glucose water every 4 hours is not a necessary action during phototherapy. The primary concern during phototherapy is to treat jaundice, and giving glucose water may not have a direct impact on the effectiveness of the treatment. Additionally, it is important to focus on monitoring the newborn's bilirubin levels and hydration status.
Choice D rationale:
Dressing the newborn in a thin layer of clothing during phototherapy is not recommended. Phototherapy works best when the newborn's skin is exposed to a light source, and covering the skin with clothing may decrease the effectiveness of the treatment.
A nurse is assessing a client who has preeclampsia during a prenatal visit. Which of the following findings should the nurse report to the provider?
A. Blood glucose 110 mg/dL.
A blood glucose level of 110 mg/dL is within the normal range for a non-pregnant individual. During pregnancy, the target range for blood glucose levels may vary, but 110 mg/dL does not typically raise concerns for preeclampsia.
B. Urine protein of 3+.
Urine protein of 3+
C. Hemoglobin 13 g/dL.
A hemoglobin level of 13 g/dL is within the normal range for a pregnant woman. While hemoglobin levels are important to monitor during pregnancy, this value alone does not indicate a significant concern related to preeclampsia.
D. Deep tendon reflexes of 2+.
Deep tendon reflexes (DTR) of 2+ are within the normal range. Higher DTR levels may be concerning, but a 2+ rating is normal and does not raise immediate alarm for preeclampsia.
Full Explanation
Choice A rationale:
A blood glucose level of 110 mg/dL is within the normal range for a non-pregnant individual. During pregnancy, the target range for blood glucose levels may vary, but 110 mg/dL does not typically raise concerns for preeclampsia.
Choice C rationale:
A haemoglobin level of 13 g/dL is within the normal range for a pregnant woman. While haemoglobin levels are important to monitor during pregnancy, this value alone does not indicate a significant concern related to preeclampsia.
Choice D rationale:
Deep tendon reflexes (DTR) of 2+ are within the normal range. Higher DTR levels may be concerning, but a 2+ rating is normal and does not raise immediate alarm for preeclampsia.