Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is 1 day postpartum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take?
A. Have the client limit the length of breastfeeding to 5 min per breast.
Limiting the length of breastfeeding to 5 minutes per breast may not address the underlying issue of sore nipples and can compromise the newborn's nutritional intake and bonding with the mother.
B. Offer supplemental formula between the newborn's feedings.
Offering supplemental formula between feedings is not indicated unless there are specific concerns about the newborn's weight gain or nutritional needs. It does not directly address the issue of sore nipples.
C. Assess the newborn's latch while breastfeeding.
Assessing the newborn's latch while breastfeeding is essential to identify if improper latch or positioning is causing the sore nipples. Correcting the latch technique can alleviate the discomfort and promote effective breastfeeding.
D. Instruct the client to wait 4 hr between daytime feedings.
Instructing the client to wait 4 hours between daytime feedings may lead to inadequate feeding for the newborn, especially during the early postpartum period when frequent feedings are essential for establishing breastfeeding and ensuring proper milk supply.
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:
Limiting the length of breastfeeding to 5 minutes per breast may not address the underlying issue of sore nipples and can compromise the newborn's nutritional intake and bonding with the mother.
Choice B rationale:
Offering supplemental formula between feedings is not indicated unless there are specific concerns about the newborn's weight gain or nutritional needs. It does not directly address the issue of sore nipples.
Choice C rationale:
Assessing the newborn's latch while breastfeeding is essential to identify if improper latch or positioning is causing sore nipples. Correcting the latch technique can alleviate the discomfort and promote effective breastfeeding.
Choice D rationale:
Instructing the client to wait 4 hours between daytime feedings may lead to inadequate feeding for the newborn, especially during the early postpartum period when frequent feedings are essential for establishing breastfeeding and ensuring proper milk supply.
Similar Questions
A nurse is caring for a client who is experiencing uterine atony immediately following delivery. The client fails to respond to oxytocin administration. The nurse should anticipate the use of which of the following medications?
A. Betamethasone.
Betamethasone is a corticosteroid used to enhance lung maturity in preterm infants and has no role in treating uterine atony.
B. Hydralazine.
Hydralazine is an antihypertensive medication used to lower blood pressure and is not indicated for the management of uterine atony.
C. Terbutaline.
Terbutaline is a tocolytic medication used to relax the uterus and delay preterm labor. It is not used to address uterine atony.
D. Methylergonovine.
Methylergonovine is an uterotonic medication commonly used to treat uterine atony by causing uterine contractions and controlling postpartum bleeding. It helps the uterus to contract and prevents further blood loss.
Full Explanation
Choice A rationale:
Betamethasone is a corticosteroid used to enhance lung maturity in preterm infants and has no role in treating uterine atony.
Choice B rationale:
Hydralazine is an antihypertensive medication used to lower blood pressure and is not indicated for the management of uterine atony.
Choice C rationale:
Terbutaline is a tocolytic medication used to relax the uterus and delay preterm labour. It is not used to address uterine atony.
Choice D rationale:
Methylergonovine is a uterotonic medication commonly used to treat uterine atony by causing uterine contractions and controlling postpartum bleeding. It helps the uterus contract and prevents further blood loss.
A nurse is assessing a client who is at 12 weeks of gestation. The nurse should report which of the following findings to the provider as an indication of an imminent spontaneous abortion?
A. Scant, bright red spotting.
Scant, bright red spotting during early pregnancy can be a normal finding known as implantation bleeding, which occurs when the embryo attaches to the uterus. It is generally not a cause for concern unless it becomes heavy and is accompanied by severe pain.
B. Elevated hCG.
Elevated hCG (human chorionic gonadotropin) levels during the first trimester are a normal part of a healthy pregnancy. hCG levels peak around 10-12 weeks of gestation and then gradually decrease. A consistent increase in hCG levels is usually a positive sign of a progressing pregnancy.
C. Cervical dilation.
Cervical dilation during the first trimester, especially when the client is only at 12 weeks of gestation, is not normal and may indicate an imminent spontaneous abortion (miscarriage). This finding should be reported promptly to the healthcare provider for further assessment and management.
D. Slight abdominal cramps.
Slight abdominal cramps can be a normal symptom during early pregnancy as the uterus undergoes changes and expands. However, unless they are severe and accompanied by other concerning signs such as heavy bleeding, they are not necessarily indicative of an imminent spontaneous abortion.
Full Explanation
Choice A rationale:
Scant, bright red spotting during early pregnancy can be a normal finding known as implantation bleeding, which occurs when the embryo attaches to the uterus. It is generally not a cause for concern unless it becomes heavy and is accompanied by severe pain.
Choice B rationale:
Elevated hCG (human chorionic gonadotropin) levels during the first trimester are a normal part of a healthy pregnancy. hCG levels peak around 10-12 weeks of gestation and then gradually decrease. A consistent increase in hCG levels is usually a positive sign of a progressing pregnancy.
Choice C rationale:
Cervical dilation during the first trimester, especially when the client is only at 12 weeks of gestation, is not normal and may indicate an imminent spontaneous abortion (miscarriage). This finding should be reported promptly to the healthcare provider for further assessment and management.
Choice D rationale:
Slight abdominal cramps can be a normal symptom during early pregnancy as the uterus undergoes changes and expands. However, unless they are severe and accompanied by other concerning signs such as heavy bleeding, they are not necessarily indicative of an imminent spontaneous abortion.
A nurse is reviewing the medical records of four clients who have an acid-base imbalance. The nurse should recognize that which of the following clients is at risk for respiratory alkalosis?
A. A client who is taking a thiazide diuretic.
Thiazide diuretics cause potassium and chloride loss, leading to metabolic alkalosis, not respiratory alkalosis. Hypokalemia decreases hydrogen ion excretion, increasing bicarbonate levels. Metabolic alkalosis is characterized by pH >7.45 and HCO₃⁻ >26 mEq/L rather than decreased PaCO₂.
B. A client who is vomiting.
Vomiting leads to metabolic alkalosis due to gastric acid loss. Hydrogen ion depletion increases bicarbonate concentration, shifting pH above normal. Arterial blood gases typically show increased HCO₃⁻ (>26 mEq/L) with a compensatory increase in PaCO₂ (>45 mmHg), not respiratory alkalosis.
C. A client who has salicylate intoxication.
Salicylate intoxication initially induces hyperventilation, reducing PaCO₂ levels below 35 mmHg and increasing pH above 7.45, leading to respiratory alkalosis. As toxicity progresses, metabolic acidosis may develop due to lactic acid accumulation, but early stages primarily present with respiratory alkalosis.
D. A client who has hypoventilation.
Hypoventilation leads to CO₂ retention, increasing PaCO₂ above 45 mmHg, forming carbonic acid (H₂CO₃) and causing respiratory acidosis. Blood gases show pH <7.35 with elevated PaCO₂, not respiratory alkalosis, which is caused by excessive CO₂ elimination through hyperventilation.
E. None
None
F. None
None
Full Explanation
The correct answer is Choice C.
Choice A rationale: Thiazide diuretics cause potassium and chloride loss, leading to metabolic alkalosis, not respiratory alkalosis. Hypokalemia decreases hydrogen ion excretion, increasing bicarbonate levels. Metabolic alkalosis is characterized by pH >7.45 and HCO₃⁻ >26 mEq/L rather than decreased PaCO₂.
Choice B rationale: Vomiting leads to metabolic alkalosis due to gastric acid loss. Hydrogen ion depletion increases bicarbonate concentration, shifting pH above normal. Arterial blood gases typically show increased HCO₃⁻ (>26 mEq/L) with a compensatory increase in PaCO₂ (>45 mmHg), not respiratory alkalosis.
Choice C rationale: Salicylate intoxication initially induces hyperventilation, reducing PaCO₂ levels below 35 mmHg and increasing pH above 7.45, leading to respiratory alkalosis. As toxicity progresses, metabolic acidosis may develop due to lactic acid accumulation, but early stages primarily present with respiratory alkalosis.
Choice D rationale: Hypoventilation leads to CO₂ retention, increasing PaCO₂ above 45 mmHg, forming carbonic acid (H₂CO₃) and causing respiratory acidosis. Blood gases show pH <7.35 with elevated PaCO₂, not respiratory alkalosis, which is caused by excessive CO₂ elimination through hyperventilation.