Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is discussing the storage of breast milk with a mother whose infant is preterm and in the special care nursery. Which statement indicates that the mother requires additional teaching?
A. “I can store my breast milk in the freezer for 3 months.”
Breast milk can be stored in the freezer for up to 3 months.
B. “I can store my breast milk in the refrigerator for 3 months.”
Storing breast milk in the refrigerator for 3 months is an incorrect statement because breast milk can only be stored in the refrigerator for up to 8 days, not 3 months.
C. “I can store my breast milk in the refrigerator for 3 to 5 days.”
Storing breast milk in the refrigerator for 3 to 5 days is a correct statement.
D. “I can store my breast milk at room temperature for 4 hours.”
Storing breast milk at room temperature for 4 hours is a correct statement.
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. Breast milk can be stored in the freezer for up to 3 months.
B. Storing breast milk in the refrigerator for 3 months is an incorrect statement because breast milk can only be stored in the refrigerator for up to 8 days, not 3 months.
C. Storing breast milk in the refrigerator for 3 to 5 days is a correct statement.
D. Storing breast milk at room temperature for 4 hours is a correct statement.
Similar Questions
A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?
A. Change the perineal pad of a client who just transferred from labor and delivery.
Changing the perineal pad of a client who has just been transferred from the labor ward is a task that should not be delegated to an assistive personnel (AP) since it is beyond their scope.
B. Monitor vital signs during admission of a client who has gestational hypertension.
Monitoring vital signs during the admission of a client with gestational hypertension requires nursing judgment and assessment skills.
C. Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum.
Providing a sitz bath to a client with a fourth-degree laceration and is 2 days post- partum can be delegated to an AP. This task does not require the nurse's clinical judgment or assessment skills, and it can be safely performed by the AP following the nurse's instructions.
D. Observe an area of redness on the breast of a client who is 1 day postpartum.
Observing an area of redness on the breast requires nursing assessment and intervention.
Full Explanation
A. Changing the perineal pad of a client who has just been transferred from the labor ward is a task that should not be delegated to an assistive personnel (AP) since it is beyond their scope.
B. Monitoring vital signs during the admission of a client with gestational hypertension requires nursing judgment and assessment skills.
C. Providing a sitz bath to a client with a fourth-degree laceration and is 2 days post- partum can be delegated to an AP. This task does not require the nurse's clinical judgment or assessment skills, and it can be safely performed by the AP following the nurse's instructions.
D. Observing an area of redness on the breast requires nursing assessment and intervention.
A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time?
A. Assess the client’s uterine fundus.
The priority is to assess the client's uterine fundus to determine if it is well-contracted. Excessive bleeding could be indicative of uterine atony, and prompt assessment is crucial for intervention.
B. Assist the client on a bedpan to urinate.
Assisting the client on a bedpan to urinate is a secondary intervention. While a distended bladder can contribute to uterine atony, assessing the fundus comes first to determine the cause.
C. Increase the client’s fluid intake.
Increasing fluid intake is important for postpartum recovery, but it is not the immediate priority in this situation.
D. Prepare to administer oxytocic medication.
Preparing to administer oxytocic medication may be necessary if uterine atony is identified during the fundal assessment. However, assessing the fundus comes first to guide appropriate interventions.
Full Explanation
A. The priority is to assess the client's uterine fundus to determine if it is well-contracted. Excessive bleeding could be indicative of uterine atony, and prompt assessment is crucial for intervention.
B. Assisting the client on a bedpan to urinate is a secondary intervention. While a distended bladder can contribute to uterine atony, assessing the fundus comes first to determine the cause.
C. Increasing fluid intake is important for postpartum recovery, but it is not the immediate priority in this situation.
D. Preparing to administer oxytocic medication may be necessary if uterine atony is identified during the fundal assessment. However, assessing the fundus comes first to guide appropriate interventions.
A nurse is preparing to administer Ringer’s lactate by continuous IV infusion at 120 mL/hr. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?
(Round the answer to the nearest whole number/tenth. Use a leading I zero if it applies. Do not use a trailing zero.)
Full Explanation
To calculate the infusion rate in gtt/min, the nurse needs to use the formula: gtt/min = (mL/hr x drop factor) / 60
Plugging in the given values, we get:
gtt/min = (120 mL/hr x 60 gtt/mL) / 60
gtt/min = 7200 gtt/hr / 60 gtt/min = 120 gtt/min
Therefore, the nurse should set the manual IV infusion to deliver 120 gtt/min.