Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn’s maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make?
A. “Look at how she looks as you when you speak. That’s a good sign.”
While visual attention to the speaker is a positive sign, routine hearing screenings provide a more accurate assessment of hearing.
B. “We do routine hearing screenings on newborns. You’ll know the results before you leave the hospital.”
Routine hearing screenings are conducted on newborns to identify hearing issues early, allowing for intervention if necessary.
C. “There is no need to worry about that. Most forms of hearing loss are not inherited.”
While most forms of hearing loss may not be inherited, it's important to assess the newborn's hearing through appropriate screenings.
D. “The best way to determine if your baby can hear is to clap your hands loudly and see if she startles.”
Startle reflex is not a reliable indicator of hearing ability, and routine screenings provide more accurate information.
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. While visual attention to the speaker is a positive sign, routine hearing screenings provide a more accurate assessment of hearing.
B. Routine hearing screenings are conducted on newborns to identify hearing issues early, allowing for intervention if necessary.
C. While most forms of hearing loss may not be inherited, it's important to assess the newborn's hearing through appropriate screenings.
D. Startle reflex is not a reliable indicator of hearing ability, and routine screenings provide more accurate information.
Similar Questions
The nurse is caring for an infant who is small for her gestational age (SGA). Which intervention is of highest priority for this infant who is at risk for hypoglycemia?
A. Ensure the infant breastfeeds in the first hour.
This intervention is correct because it provides the infant with a source of glucose and helps prevent hypoglycemia.
B. Perform a glucose test for the infant before feeding.
A glucose test alone may not provide timely intervention if hypoglycemia is detected.
C. Administer intravenous dextrose infusion within 2 hours.
Administering intravenous dextrose infusion is a rapid and effective way to address hypoglycemia, but early breastfeeding should be the priority action.
D. Ensure the infant is fed every hour for the first 24 hours.
While frequent feeding is beneficial, intravenous dextrose may be necessary for a more immediate impact.
Full Explanation
A. This intervention is correct because it provides the infant with a source of glucose and helps prevent hypoglycemia.
B. A glucose test alone may not provide timely intervention if hypoglycemia is detected.
C. Administering intravenous dextrose infusion is a rapid and effective way to address hypoglycemia, but early breastfeeding should be the priority action.
D. While frequent feeding is beneficial, intravenous dextrose may be necessary for a more immediate impact.
A nurse is assessing a newborn immediately following a scheduled cesarean delivery.
Which of the following assessments is the nurse’s priority?
A. Respiratory distress
Assessing for respiratory distress is the priority as the newborn's ability to breathe independently is crucial immediately after birth.
B. Acrocyanosis.
Acrocyanosis is a common and expected finding in newborns, especially in the first few hours after birth.
C. Accidental lacerations
Accidental lacerations, while important to assess, are not as immediately critical as respiratory distress.
D. Hypothermia
While hypothermia is a concern, addressing respiratory distress takes precedence in the immediate postoperative period.
Full Explanation
A. Assessing for respiratory distress is the priority as the newborn's ability to breathe independently is crucial immediately after birth.
B. Acrocyanosis is a common and expected finding in newborns, especially in the first few hours after birth.
C. Accidental lacerations, while important to assess, are not as immediately critical as respiratory distress.
D. While hypothermia is a concern, addressing respiratory distress takes precedence in the immediate postoperative period.
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.
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.