Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is postpartum and experiencing hypovolemic shock.
Which of the following findings should the nurse expect?
A. Cool, clammy skin.
A client who is postpartum and experiencing hypovolemic shock would have cool, clammy skin. This is because hypovolemic shock severely limits the body’s ability to get blood to all of its organs.
B. Urinary output 30 mL/hr.
Choice B is not correct because a urinary output of 30 mL/hr is within the normal range.
C. Bounding pulses.
Choice C is not correct because a client experiencing hypovolemic shock would have a weak pulse, not a bounding one.
D. Respiratory rate 18/min.
Choice D is not correct because a respiratory rate of 18/min is within the normal range, while a client experiencing hypovolemic shock would have an increased respiratory rate.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Maternal Newborn 2019 with NGN Proctored Exam. Take the full exam now
Full Explanation
A client who is postpartum and experiencing hypovolemic shock would have cool, clammy skin.
This is because hypovolemic shock severely limits the body’s ability to get blood
to all of its organs.
Choice B is not correct because a urinary output of 30 mL/hr is within the
normal range.
Choice C is not correct because a client experiencing hypovolemic shock would have a weak pulse, not a bounding one.
Choice D is not correct because a respiratory rate of 18/min is within the normal range, while a client experiencing hypovolemic shock would have an increased respiratory rate.
Similar Questions
A nurse is assessing a client who is at 32 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion.
Which of the following findings should the nurse report to the provider?
A. Decrease in frequency of contractions.
Choice A is not correct because a decrease in the frequency of contractions is an expected outcome of magnesium sulfate use as a tocolytic to stop preterm labor.
B. Urinary output 35 mL/hr.
Choice B is not correct because a urinary output of 35 mL/hr is within the normal range.
C. Absent deep-tendon reflexes.
A nurse should report absent deep-tendon reflexes to the provider when a client is receiving magnesium sulfate via continuous IV infusion 1. This is because reduced tendon reflexes can be a side effect of magnesium sulfate use during pregnancy.
D. BP 150/100 mm Hg.
Choice D is not correct because an elevated blood pressure is not a known side effect of magnesium sulfate use during pregnancy.
Full Explanation
A nurse should report absent deep-tendon reflexes to the provider when a client is receiving magnesium sulfate via continuous IV infusion.
This is because reduced tendon reflexes can be a side effect of magnesium sulfate use during pregnancy.
Choice A is not correct because a decrease in the frequency of contractions is an expected outcome of magnesium sulfate use as a tocolytic to stop preterm labor.
Choice B is not correct because a urinary output of 35 mL/hr is within the normal range.
Choice D is not correct because an elevated blood pressure is not a known side effect of magnesium sulfate use during pregnancy.
A nurse is caring for a client who is receiving oxytocin to induce labor.
The nurse should discontinue the oxytocin if which of the following occurs?
A. Six contractions in 10 min.
A nurse should discontinue oxytocin if the client experiences uterine hyperkinesia, which is defined as more than 5 contractions in 10 minutes.
B. Contractions last 60 seconds.
Choice B is not correct because contractions lasting 60 seconds are within the normal range.
C. Moderate variability of the fetal heart rate.
Choice C is not correct because moderate variability of the fetal heart rate is a reassuring sign.
D. Nonrepetitive early decelerations.
Choice D is not correct because nonrepetitive early decelerations are generally considered benign and do not require intervention.
Full Explanation
A nurse should discontinue oxytocin if the client experiences uterine hyperkinesia, which is defined as more than 5 contractions in 10 minutes.
Choice B is not correct because contractions lasting 60 seconds are within the normal range.
Choice C is not correct because moderate variability of the fetal heart rate is a reassuring sign.
Choice D is not correct because nonrepetitive early decelerations are generally considered benign and do not require intervention.
A nurse is caring for a newborn following delivery.
Which of the following actions should the nurse take first?
A. Apply prophylactic eye ointment.
Applying prophylactic eye ointment (choice A), administering vitamin K (choice B), and obtaining the newborn’s weight (choice C) can be done after the identification bands have been applied.
B. Administer vitamin K.
Applying prophylactic eye ointment (choice A), administering vitamin K (choice B), and obtaining the newborn’s weight (choice C) can be done after the identification bands have been applied.
C. Obtain the newborn's weight.
Applying prophylactic eye ointment (choice A), administering vitamin K (choice B), and obtaining the newborn’s weight (choice C) can be done after the identification bands have been applied.
D. Apply identification bands to the newborn.
The first action the nurse should take is to apply identification bands to the newborn (choice D). This is an important step in ensuring the safety and security of the newborn and helps to prevent errors such as misidentification. Choices A, B, and C are also important actions that should be taken when caring for a newborn following delivery. However, applying prophylactic eye ointment (choice A), administering vitamin K (choice B), and obtaining the newborn’s weight (choice C) can be done after the identification bands have been applied.
Full Explanation
The first action the nurse should take is to apply identification bands to the newborn (choice D).
This is an important step in ensuring the safety and security of the newborn and helps to prevent errors such as misidentification.
Choices A, B, and C are also important actions that should be taken when caring for a newborn following delivery.
However, applying prophylactic eye ointment (choice A), administering vitamin K (choice B), and obtaining the newborn’s weight (choice C) can be done after the identification bands have been applied.