Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a newborn immediately following delivery. After assuring a patent airway, which of the following actions should be the nurse's priority?
A. Dry the newborn.
Drying the newborn's skin thoroughly is the nurse's priority after assuring a patent airway because it reduces evaporative heat loss by the newborn and prevents cold stress. Cold stress can lead to hypoxia, hypoglycemia, acidosis, and increased bilirubin levels. Drying the newborn also stimulates breathing and crying, which are signs of a healthy newborn.
B. Administer phytonadione IM.
Administering phytonadione IM is not the nurse's priority because it is not an immediate life- saving intervention. Phytonadione is given to prevent hemorrhagic disease of the newborn, which is caused by vitamin K deficiency. However, this condition usually occurs after the first day of life, so administering phytonadione can be delayed until after the initial assessment and stabilization of the newborn.
C. Document the Apgar score.
Documenting the Apgar score is not the nurse's priority because it is not an action that directly affects the newborn's well-being. The Apgar score is a tool to assess the newborn's condition at 1 and 5 minutes after birth based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. The Apgar score can help guide the nurse's interventions, but it is not more important than providing care to the newborn.
D. Apply identification bands.
Applying identification bands is not the nurse's priority because it is not an urgent or essential action. Identification bands are used to ensure the safety and security of the newborn and prevent errors or mix-ups. However, applying identification bands can be done after the newborn is dried, warmed, and assessed for any problems.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom Maternity Final 23D Proctored Exam. Take the full exam now
Full Explanation
Choice A reason:
Drying the newborn's skin thoroughly is the nurse's priority after assuring a patent airway because it reduces evaporative heat loss by the newborn and prevents cold stress. Cold stress can lead to hypoxia, hypoglycemia, acidosis, and increased bilirubin levels. Drying the newborn also stimulates breathing and crying, which are signs of a healthy newborn.
Choice B reason:
Administering phytonadione IM is not the nurse's priority because it is not an immediate life-saving intervention. Phytonadione is given to prevent hemorrhagic disease of the newborn, which is caused by vitamin K deficiency. However, this condition usually occurs after the first day of life, so administering phytonadione can be delayed until after the initial assessment and stabilization of the newborn.
Choice C reason:
Documenting the Apgar score is not the nurse's priority because it is not an action that directly affects the newborn's well-being. The Apgar score is a tool to assess the newborn's condition at 1 and 5 minutes after birth based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. The Apgar score can help guide the nurse's interventions, but it is not more important than providing care to the newborn.
Choice D reason:
Applying identification bands is not the nurse's priority because it is not an urgent or essential action. Identification bands are used to ensure the safety and security of the newborn and prevent errors or mix-ups. However, applying identification bands can be done after the newborn is dried, warmed, and assessed for any problems.
Similar Questions
A nurse is collecting data from a newborn who has respiratory distress syndrome and is experiencing respiratory acidosis. Which of the following risk factors predisposes the newborn to respiratory difficulties?
A. Small for gestational age.
Small for gestational age (SGA) newborns are at risk for respiratory distress syndrome (RDS) and respiratory acidosis because they have immature lungs that produce less surfactant, which is needed to keep the alveoli open and prevent atelectasis. SGA newborns also have less glycogen stores, which can lead to hypoglycemia and impaired oxygen delivery to the tissues.
B. Maternal history of asthma.
Maternal history of asthma is not a risk factor for RDS or respiratory acidosis in the newborn. Asthma is a chronic inflammatory disorder of the airways that affects the mother, not the fetus. Maternal asthma can cause complications such as preterm labor, preeclampsia, or intrauterine growth restriction, but it does not directly affect the fetal lung development or function.
C. Ventricular septal defect.
Ventricular septal defect (VSD) is a congenital heart defect that causes a hole in the wall between the ventricles of the heart. This can result in increased pulmonary blood flow and pressure, which can lead to pulmonary edema and heart failure in the newborn. However, VSD does not cause RDS or respiratory acidosis, which are related to lung maturity and surfactant production.
D. Cesarean birth.
Cesarean birth is not a risk factor for RDS or respiratory acidosis in the newborn. Cesarean birth can increase the risk of transient tachypnea of the newborn (TTN), which is caused by delayed absorption of fetal lung fluid. TTN usually resolves within 24 to 48 hours and does not cause a significant acid-base imbalance in the newborn.
Full Explanation
Choice A reason:
Small for gestational age (SGA) newborns are at risk for respiratory distress syndrome (RDS) and respiratory acidosis because they have immature lungs that produce less surfactant, which is needed to keep the alveoli open and prevent atelectasis. SGA newborns also have less glycogen stores, which can lead to hypoglycemia and impaired oxygen delivery to the tissues.
Choice B reason:
Maternal history of asthma is not a risk factor for RDS or respiratory acidosis in the newborn. Asthma is a chronic inflammatory disorder of the airways that affects the mother, not the fetus. Maternal asthma can cause complications such as preterm labor, preeclampsia, or intrauterine growth restriction, but it does not directly affect the fetal lung development or function.
Choice C reason:
Ventricular septal defect (VSD) is a congenital heart defect that causes a hole in the wall between the ventricles of the heart. This can result in increased pulmonary blood flow and pressure, which can lead to pulmonary edema and heart failure in the newborn. However, VSD does not cause RDS or respiratory acidosis, which are related to lung maturity and surfactant production.
Choice D reason:
Cesarean birth is not a risk factor for RDS or respiratory acidosis in the newborn. Cesarean birth can increase the risk of transient tachypnea of the newborn (TTN), which is caused by delayed absorption of fetal lung fluid. TTN usually resolves within 24 to 48 hours and does not cause a significant acid-base imbalance in the newborn.
A nurse is caring for a client who is postpartum. The nurse should recognize which of the following statements by the client as a possible indicator of inhibition of parental attachment?
A. "I don't need the bath demonstration. I know how to do it.".
This statement does not indicate inhibition of parental attachment. The client may have prior experience or knowledge of bathing a newborn and may not need the demonstration. The nurse should respect the client's autonomy and confidence in this skill.
B. "Do you think you could keep him in the nursery for the next feeding so I can get some sleep?.".
This statement does not indicate inhibition of parental attachment. The client may be exhausted from the labor and delivery process and may need some rest to recover. The nurse should support the client's request and ensure that the newborn is well cared for in the nursery.
C. "I just wish he had more hair. I'm going to have to keep a hat on his head till he grows some.".
This statement indicates inhibition of parental attachment. The client expresses dissatisfaction with the newborn's appearance and implies that the newborn is not attractive enough. The nurse should explore the client's feelings and expectations about the newborn and provide reassurance and education about normal variations in newborn features.
D. "He's got my husband's nose, that's for sure.".
This statement does not indicate inhibition of parental attachment. The client recognizes a family resemblance in the newborn and expresses a positive connection with the newborn and the partner. The nurse should acknowledge the client's observation and encourage further bonding with the newborn.
Full Explanation
Choice A reason:
This statement does not indicate inhibition of parental attachment. The client may have prior experience or knowledge of bathing a newborn and may not need the demonstration. The nurse should respect the client's autonomy and confidence in this skill.
Choice B reason:
This statement does not indicate inhibition of parental attachment. The client may be exhausted from the labor and delivery process and may need some rest to recover. The nurse should support the client's request and ensure that the newborn is well cared for in the nursery.
Choice C reason:
This statement indicates inhibition of parental attachment. The client expresses dissatisfaction with the newborn's appearance and implies that the newborn is not attractive enough. The nurse should explore the client's feelings and expectations about the newborn and provide reassurance and education about normal variations in newborn features.
Choice D reason:
This statement does not indicate inhibition of parental attachment. The client recognizes a family resemblance in the newborn and expresses a positive connection with the newborn and the partner. The nurse should acknowledge the client's observation and encourage further bonding with the newborn.
What is the most significant risk factor for clubfoot?
A. Smoking
Smoking is the most significant risk factor for clubfoot, according to several studies that have found a strong association between maternal smoking during pregnancy and the occurrence of clubfoot in the offspring. Smoking may affect the development of the muscles and tendons in the fetus, leading to abnormal positioning of the foot.
B. Trauma during pregnancy
Trauma during pregnancy is not a significant risk factor for clubfoot, as there is no evidence that physical injury to the mother or the fetus can cause this deformity. Clubfoot is a congenital condition that is present at birth and usually detected by prenatal ultrasound.
C. Hypertension
Hypertension is not a significant risk factor for clubfoot, as there is no evidence that high blood pressure in the mother or the fetus can cause this deformity. Clubfoot is a congenital condition that is present at birth and usually detected by prenatal ultrasound.
D. Decreased circulation
Decreased circulation is not a significant risk factor for clubfoot, as there is no evidence that poor blood flow to the mother or the fetus can cause this deformity. Clubfoot is a congenital condition that is present at birth and usually detected by prenatal ultrasound.
Full Explanation
Choice A reason:
Smoking is the most significant risk factor for clubfoot, according to several studies that have found a strong association between maternal smoking during pregnancy and the occurrence of clubfoot in the offspring. Smoking may affect the development of the muscles and tendons in the fetus, leading to abnormal positioning of the foot.
Choice B reason:
Trauma during pregnancy is not a significant risk factor for clubfoot, as there is no evidence that physical injury to the mother or the fetus can cause this deformity. Clubfoot is a congenital condition that is present at birth and usually detected by prenatal ultrasound.
Choice C reason:
Hypertension is not a significant risk factor for clubfoot, as there is no evidence that high blood pressure in the mother or the fetus can cause this deformity. Clubfoot is a congenital condition that is present at birth and usually detected by prenatal ultrasound.
Choice D reason:
Decreased circulation is not a significant risk factor for clubfoot, as there is no evidence that poor blood flow to the mother or the fetus can cause this deformity. Clubfoot is a congenital condition that is present at birth and usually detected by prenatal ultrasound.