Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is in active labor. The nurse administers butorphanol IV bolus for pain. Which of the following findings should the nurse report to the provider following this medication?
A. Blood pressure 136/88 mm Hg.
Blood pressure of 136/88 mm Hg should be monitored, but it is not a finding that the nurse needs to urgently report to the provider following the administration of butorphanol. The blood pressure reading is slightly elevated but might be attributed to pain or anxiety during labor.
B. Moderate fetal heart rate variability.
Moderate fetal heart rate variability is a reassuring sign of fetal well-being and is an expected finding during labor. It does not require immediate reporting to the provider.
C. Respiratory rate 100/min.
Respiratory rate of 100/min is significantly increased and should be reported to the provider following the administration of butorphanol. Respiratory depression is a potential side effect of opioids like butorphanol, and a respiratory rate of 100/min raises concern for potential respiratory compromise.
D. Urinary output 120 mL in 2 hr.
Urinary output of 120 mL in 2 hours is an acceptable finding during labor and does not require immediate reporting to the provider. Adequate urinary output varies, but generally, 30 mL/hour is considered acceptable during labor.
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:
Blood pressure of 136/88 mm Hg should be monitored, but it is not a finding that the nurse needs to urgently report to the provider following the administration of butorphanol. The blood pressure reading is slightly elevated but might be attributed to pain or anxiety during labor.
Choice B rationale:
Moderate fetal heart rate variability is a reassuring sign of fetal well-being and is an expected finding during labor. It does not require immediate reporting to the provider.
Choice C rationale:
Respiratory rate of 100/min is significantly increased and should be reported to the provider following the administration of butorphanol. Respiratory depression is a potential side effect of opioids like butorphanol, and a respiratory rate of 100/min raises concern for potential respiratory compromise.
Choice D rationale:
Urinary output of 120 mL in 2 hours is an acceptable finding during labor and does not require immediate reporting to the provider. Adequate urinary output varies, but generally, 30 mL/hour is considered acceptable during labor.
Similar Questions
A nurse is performing an assessment for a newborn and notes breast tissue that has a flat areola with no bud. The nurse should identify that this finding indicates which of the following conditions?
A. Preterm gestational age.
Flat areola without breast bud indicates immature breast tissue development, a marker of preterm gestational age due to incomplete fetal maturation of secondary sexual characteristics.
B. Decreased maternal hormones during pregnancy.
Decreased maternal hormones during pregnancy would result in less developed breast tissue in the newborn, but it wouldn't present as a flat areola with no bud. Instead, the breast tissue may be small and less pronounced.
C. Congenital anomaly.
Congenital anomalies involve structural malformations, not absence of breast bud, which is a normal developmental stage in preterm infants rather than a pathological anomaly.
D. Ambiguous secondary sex characteristics.
Ambiguous secondary sex characteristics would involve the presence of characteristics that are not clearly male or female. The described breast tissue does not fit this category, as it is specifically described as having a flat areola with no bud, which is more indicative of a congenital anomaly. Question 65.
Full Explanation
Choice A rationale: Flat areola without breast bud indicates immature breast tissue development, a marker of preterm gestational age due to incomplete fetal maturation of secondary sexual characteristics.
Choice B rationale: Maternal hormones influence neonatal breast tissue temporarily, but absence of bud reflects developmental immaturity rather than decreased maternal hormones during pregnancy.
Choice C rationale: Congenital anomalies involve structural malformations, not absence of breast bud, which is a normal developmental stage in preterm infants rather than a pathological anomaly.
Choice D rationale: Ambiguous secondary sex characteristics refer to atypical genital or pubertal development, not neonatal breast tissue maturity, making this unrelated to the flat areola finding.
A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse assess first?
A. A client who has placenta previa and a hematocrit of 36%.
A client with placenta previa and a hematocrit of 36% should be monitored closely due to the risk of bleeding, but it is not an immediate priority compared to the client with hyperemesis gravidarum and a low sodium level.
B. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L.
Hyperemesis gravidarum is a severe form of morning sickness characterized by excessive vomiting, leading to dehydration and electrolyte imbalances. A sodium level of 110 mEq/L is dangerously low and requires immediate attention to correct the electrolyte disturbance and prevent further complications.
C. A client who has diabetes mellitus and an HbA1c of 5.8%.
A client with diabetes mellitus and an HbA1c of 5.8% is within a normal range, indicating good glycemic control. This client's condition can be managed on an outpatient basis and does not require urgent assessment compared to the others.
D. A client who has preeclampsia and a creatinine level of 1.1 mg/dL.
A client with preeclampsia and a creatinine level of 1.1 mg/dL should be closely monitored, but it is not the priority over the client with hyperemesis gravidarum and severe electrolyte imbalance.
Full Explanation
Choice A rationale:
A client with placenta previa and a hematocrit of 36% should be monitored closely due to the risk of bleeding, but it is not an immediate priority compared to the client with hyperemesis gravidarum and a low sodium level.
Choice B rationale:
Hyperemesis gravidarum is a severe form of morning sickness characterized by excessive vomiting, leading to dehydration and electrolyte imbalances. A sodium level of 110 mEq/L is dangerously low and requires immediate attention to correct the electrolyte disturbance and prevent further complications.
Choice C rationale:
A client with diabetes mellitus and an HbA1c of 5.8% is within a normal range, indicating good glycemic control. This client's condition can be managed on an outpatient basis and does not require urgent assessment compared to the others.
Choice D rationale:
A client with preeclampsia and a creatinine level of 1.1 mg/dL should be closely monitored, but it is not the priority over the client with hyperemesis gravidarum and severe electrolyte imbalance.
A nurse is providing discharge teaching to a postpartum client about caring for her 5-day-old male newborn at home. Which of the following statements should the nurse make to the client?
A. "Swaddle your baby tightly with his legs extended before laying him down to sleep.".
Swaddling the baby tightly with his legs extended before laying him down to sleep is not a recommended practice, as it can increase the risk of hip dysplasia. Instead, the baby should be placed on their back in a safe sleep environment.
B. "Notify your baby's pediatrician if he urinates less than six times a day.".
This statement is correct because monitoring the baby's urinary output is essential in ensuring adequate hydration and proper kidney function. Less than six wet diapers a day could be a sign of dehydration and should be promptly reported to the pediatrician.
C. "Retract the foreskin to clean your baby's penis during each bath.".
It is not necessary to retract the foreskin to clean the baby's penis during each bath. The foreskin should be left alone and not forcibly retracted until it naturally loosens, usually around the age of 3 to 5 years.
D. "Place triple antibiotic ointment on your baby's umbilical cord twice per day."
Applying triple antibiotic ointment on the baby's umbilical cord is not recommended, as the standard practice is to keep the umbilical cord clean and dry. This helps it to fall off naturally within a week or two after birth, reducing the risk of infection.
Full Explanation
Choice A rationale:
Swaddling the baby tightly with his legs extended before laying him down to sleep is not a recommended practice, as it can increase the risk of hip dysplasia. Instead, the baby should be placed on their back in a safe sleep environment.
Choice B rationale:
This statement is correct because monitoring the baby's urinary output is essential in ensuring adequate hydration and proper kidney function. Less than six wet diapers a day could be a sign of dehydration and should be promptly reported to the pediatrician.
Choice C rationale:
It is not necessary to retract the foreskin to clean the baby's penis during each bath. The foreskin should be left alone and not forcibly retracted until it naturally loosens, usually around the age of 3 to 5 years.
Choice D rationale:
Applying triple antibiotic ointment on the baby's umbilical cord is not recommended, as the standard practice is to keep the umbilical cord clean and dry. This helps it to fall off naturally within a week or two after birth, reducing the risk of infection.