Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn’s nose and mouth. Which of the following actions is the nurse’s priority?
A. Turn the newborn on his side.
Turning the newborn on his side may be done after suctioning but is not the initial priority.
B. Use a suction catheter with low negative pressure.
Using a suction catheter with low negative pressure may be appropriate, but a bulb syringe is commonly used for newborns.
C. Suction the mouth with a bulb syringe.
Suctioning the mouth is a necessary step to ensure effective breathing.
D. Suction the nose with a bulb syringe
Suctioning the nose with a bulb syringe is the priority to clear the airway and facilitate breathing in the presence of secretions.
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. Turning the newborn on his side may be done after suctioning but is not the initial priority.
B. Using a suction catheter with low negative pressure may be appropriate, but a bulb syringe is commonly used for newborns.
C. Suctioning the mouth is a necessary step to ensure effective breathing.
D. Suctioning the nose first may cause the infant to gasp and potentially draw the secretions present in the mouth into the airway, which could lead to aspiration.
Similar Questions
A nurse is reinforcing teaching about newborn care with a postpartum client. Which of the following statements by the client indicates a need for further teaching?
A. “I will use mild soap.”
Using mild soap is a suitable practice for newborn skin care.
B. “I will test the water on my wrist for temperature before bathing.”
Testing water temperature before bathing is a safety measure to prevent burns.
C. “Baby powder will help prevent a diaper rash.”
Baby powder is not recommended for newborns as it can cause respiratory issues when inhaled.
D. “I will use a basin during bathing.”
Using a basin during bathing is a reasonable approach to facilitate safe and controlled bathing.
Full Explanation
A. Using mild soap is a suitable practice for newborn skin care.
B. Testing water temperature before bathing is a safety measure to prevent burns.
C. Baby powder is not recommended for newborns as it can cause respiratory issues when inhaled.
D. Using a basin during bathing is a reasonable approach to facilitate safe and controlled bathing.
A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle feed. During the assessment, the nurse notices that both breasts are swollen, warm, and tender on palpation. Which guidance should the nurse provide to the client at this time?
A. Wearing a loose-fitting bra to prevent nipple irritation.
Wearing a loose-fitting bra may provide comfort but does not address the underlying issue of engorgement.
B. Express small amounts of milk from the breasts to relieve the pressure.
Expressing small amounts of milk may stimulate further milk production and is not recommended in cases of bottle-feeding.
C. Run warm water on her breasts during a shower.
Running warm water on the breasts may increase blood flow and exacerbate swelling.
D. Apply ice to the breasts for comfort.
Cold compresses or ice are more appropriate for relieving discomfort and reducing swelling.
Full Explanation
A. Wearing a loose-fitting bra may provide comfort but does not address the underlying issue of engorgement.
B. Expressing small amounts of milk may stimulate further milk production and is not recommended in cases of bottle-feeding.
C. Running warm water on the breasts may increase blood flow and exacerbate swelling.
D. Cold compresses or ice are more appropriate for relieving discomfort and reducing swelling.
While examining a newborn, the nurse notes uneven skinfolds on the buttocks and a clunk when performing the Ortolani maneuver. These findings are likely indicative of what?
A. Webbing
Webbing typically refers to the presence of extra skin between body parts and is not associated with uneven skinfolds on the buttocks or a clunk during the Ortolani maneuver.
B. Clubfoot
Clubfoot refers to a deformity of the foot and is not associated with uneven skinfolds on the buttocks or hip abnormalities.
C. Hip dysplasia
Uneven skinfolds on the buttocks and a clunk during the Ortolani maneuver are indicative of hip dysplasia in a newborn.
D. Polydactyly
Polydactyly refers to the presence of extra fingers or toes and is unrelated to the described findings.
Full Explanation
A. Webbing typically refers to the presence of extra skin between body parts and is not associated with uneven skinfolds on the buttocks or a clunk during the Ortolani maneuver.
B. Clubfoot refers to a deformity of the foot and is not associated with uneven skinfolds on the buttocks or hip abnormalities.
C. Uneven skinfolds on the buttocks and a clunk during the Ortolani maneuver are indicative of hip dysplasia in a newborn.
D. Polydactyly refers to the presence of extra fingers or toes and is unrelated to the described findings.