Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The fundus is midline and firm at the umbilicus.
Which of the following actions should the nurse take?.
A. Notify the client's provider.
Notifying the provider is not necessary in this case as the findings are normal for a client who is 1 hour postpartum.
B. Increase the frequency of fundal massage.
Increasing the frequency of fundal massage is not necessary as the fundus is firm and at the umbilicus.
C. Document the findings and continue to monitor the client.
The findings are normal for a client who is 1 hour postpartum. The nurse should document the findings and continue to monitor the client. Therefore, this choice is correct.
D. Encourage the client to empty her bladder.
Encouraging the client to empty her bladder is not necessary in this case as the fundus is midline.
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 C.
Choice A rationale:
Notifying the provider is not necessary in this case as the findings are normal for a client who is 1 hour postpartum.
Choice B rationale:
Increasing the frequency of fundal massage is not necessary as the fundus is firm and at the umbilicus.
Choice C rationale:
The findings are normal for a client who is 1 hour postpartum. The nurse should document the findings and continue to monitor the client. Therefore, this choice is correct.
Choice D rationale:
Encouraging the client to empty her bladder is not necessary in this case as the fundus is midline.
Similar Questions
A nurse is caring for a client who is postpartum and has a prescription for Rho (D) immunoglobulin.
The nurse should verify which of the following prior to administration?.
A. Client is Rh negative and the newborn is Rh negative.
Rho (D) immunoglobulin is not administered when both the client and the newborn are Rh negative.
B. Client is Rh positive and the newborn is Rh positive.
Rho (D) immunoglobulin is not administered when both the client and the newborn are Rh positive.
C. Client is Rh positive and the newborn is Rh negative.
Rho (D) immunoglobulin is not administered when the client is Rh positive and the newborn is Rh negative.
D. Client is Rh negative and the newborn is Rh positive.
Rho (D) immunoglobulin is administered when the client is Rh negative and the newborn is Rh positive. Therefore, this choice is correct.
Full Explanation
The correct answer is choice D.
Choice A rationale:
Rho (D) immunoglobulin is not administered when both the client and the newborn are Rh negative.
Choice B rationale:
Rho (D) immunoglobulin is not administered when both the client and the newborn are Rh positive.
Choice C rationale:
Rho (D) immunoglobulin is not administered when the client is Rh positive and the newborn is Rh negative.
Choice D rationale:
Rho (D) immunoglobulin is administered when the client is Rh negative and the newborn is Rh positive. Therefore, this choice is correct.
A nurse is providing teaching about comfort measures for breast engorgement to a client who is postpartum and is breastfeeding.
Which of the following statements by the client indicates a need for further teaching?.
A. "I should crush cabbage leaves and place them on my breasts.”. .
Cabbage leaves have been used for many years for relief of breast engorgement. They can be crushed slightly until the juice is visible and then chilled in the refrigerator before applying to the breasts.
B. "I should apply hot packs to my breasts during feeding.”. .
Applying hot packs during feeding can actually increase blood flow and make engorgement worse. Cold packs should be used after feeding to help reduce swelling.
C. "I will apply ice packs to my breasts after feeding.”. .
Applying ice packs after feeding can help reduce swelling and provide relief from engorgement.
D. "I will breastfeed every 2 hours.”.
Frequent breastfeeding can help to relieve engorgement. The breasts should be emptied completely at each feeding.
Full Explanation
The correct answer is choice B.
Choice A rationale:
Cabbage leaves have been used for many years for relief of breast engorgement. They can be crushed slightly until the juice is visible and then chilled in the refrigerator before applying to the breasts.
Choice B rationale:
Applying hot packs during feeding can actually increase blood flow and make engorgement worse. Cold packs should be used after feeding to help reduce swelling.
Choice C rationale:
Applying ice packs after feeding can help reduce swelling and provide relief from engorgement.
Choice D rationale:
Frequent breastfeeding can help to relieve engorgement. The breasts should be emptied completely at each feeding.
What should the nurse expect for a full-term newborn's weight during the first few days of life?.
A. There is a loss of 5% to 10% of the birth weight in the first few days in breastfed infants only.
While it’s true that breastfed infants may lose 5% to 10% of their birth weight in the first few days, this is not exclusive to breastfed infants.
B. There is an increase in 3% to 5% of birth weight by day 3 in formula-fed babies.
Formula-fed babies may gain weight more quickly than breastfed babies, but they do not typically show an increase in weight by day 3.
C. There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns.
Both formula-fed and breastfed newborns can lose 5% to 10% of their birth weight in the first few days.
D. A formula-fed newborn should gain 3% to 5% of the initial birth weight in the first 48 hours, but a breastfed newborn may lose up to 3%.
While formula-fed newborns may gain weight more quickly than breastfed newborns, they do not typically gain 3% to 5% of the initial birth weight in the first 48 hours.
Full Explanation
The correct answer is choice C.
Choice A rationale:
While it’s true that breastfed infants may lose 5% to 10% of their birth weight in the first few days, this is not exclusive to breastfed infants.
Choice B rationale:
Formula-fed babies may gain weight more quickly than breastfed babies, but they do not typically show an increase in weight by day 3.
Choice C rationale:
Both formula-fed and breastfed newborns can lose 5% to 10% of their birth weight in the first few days.
Choice D rationale:
While formula-fed newborns may gain weight more quickly than breastfed newborns, they do not typically gain 3% to 5% of the initial birth weight in the first 48 hours.