Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is performing a heel stick on a newborn. Which of the following actions should the nurse take?
A. Puncture the heel on the inner aspect of the foot.
Choice A is incorrect because the heel should be punctured on the outer aspect of the foot to avoid damaging the calcaneus bone.
B. Use an automatic puncture device on the heel.
“Use an automatic puncture device on the heel.” This is the most common and minimally invasive method to draw capillary blood from an infant for medical testing.
C. Cleanse the newborn's heel with an alcohol swab after the procedure.
Choice C is incorrect because the heel should be cleansed with an alcohol swab before, not after, the procedure.
D. Place an ice pack on the newborn's heel 5 min before the procedure.
Choice D is incorrect because there is no need to place an ice pack on the newborn’s heel before the procedure.
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
“Use an automatic puncture device on the heel.” This is the most common and minimally invasive method to draw capillary blood from an infant for medical testing.
Choice A is incorrect because the heel should be punctured on the outer aspect of the foot to avoid damaging the calcaneus bone.
Choice C is incorrect because the heel should be cleansed with an alcohol swab
before, not after, the procedure.
Choice D is incorrect because there is no need to place an ice pack on the newborn’s heel before the procedure.
Similar Questions
A nurse is assessing a full-term newborn upon admission to the nursery.
Which of the following clinical findings should the nurse report to the provider?
A. Rust-stained urine.
Rust or brick-dust staining in the diaper is usually caused by urate crystals in the urine. This is a common and benign finding in newborns during the first days of life, particularly when fluid intake is still low. It does not require provider notification unless it persists beyond the first week or is accompanied by other abnormalities.
B. Subconjunctival hemorrhage.
A subconjunctival hemorrhage often results from pressure during delivery, especially in vaginal births. It appears as a bright red patch on the sclera but is harmless and resolves spontaneously within several weeks. It is considered a normal newborn finding and does not need to be reported.
C. Single palmar creases.
A single transverse palmar crease, also known as a simian crease, can be associated with chromosomal abnormalities such as Down syndrome. While it may sometimes be an isolated normal variant, its presence warrants further evaluation. The nurse should report this finding to the provider for assessment and potential genetic follow-up
D. Transient circumoral cyanosis.
Brief bluish discoloration around the lips in a newborn is typically due to vasomotor instability and is common when the infant is crying or cold. As long as the central mucous membranes remain pink and oxygenation is normal, this finding is not concerning and usually resolves without intervention.
Full Explanation
Rationales
A. Rust-stained urine.
Rust or brick-dust staining in the diaper is usually caused by urate crystals in the urine. This is a common and benign finding in newborns during the first days of life, particularly when fluid intake is still low. It does not require provider notification unless it persists beyond the first week or is accompanied by other abnormalities.
B. Subconjunctival hemorrhage.
A subconjunctival hemorrhage often results from pressure during delivery, especially in vaginal births. It appears as a bright red patch on the sclera but is harmless and resolves spontaneously within several weeks. It is considered a normal newborn finding and does not need to be reported.
C. Single palmar creases.
A single transverse palmar crease, also known as a simian crease, can be associated with chromosomal abnormalities such as Down syndrome. While it may sometimes be an isolated normal variant, its presence warrants further evaluation. The nurse should report this finding to the provider for assessment and potential genetic follow-up.
D. Transient circumoral cyanosis.
Brief bluish discoloration around the lips in a newborn is typically due to vasomotor instability and is common when the infant is crying or cold. As long as the central mucous membranes remain pink and oxygenation is normal, this finding is not concerning and usually resolves without intervention.
A nurse is caring for a client who is at 30 weeks of gestation and is receiving magnesium sulfate for preeclampsia.
The nurse should recognize which of the following manifestations as an adverse reaction to the medication?
A. Hypertension.
Choice A is incorrect because magnesium sulfate is used to treat hypertension associated with preeclampsia.
B. Respiratory rate 16/min.
Choice B is incorrect because a respiratory rate of 16/min is within normal range.
C. Urine output 20 mL/hr.
This can be a sign of magnesium toxicity and should be reported to the provider.
D. Hyperglycemia.
Choice D is incorrect because hyperglycemia is not a known adverse reaction to magnesium sulfate.
E. Hyperglycemia.
Full Explanation
This can be a sign of magnesium toxicity and should be reported to the provider.
Choice A is incorrect because magnesium sulfate is used to treat hypertension associated with preeclampsia.
Choice B is incorrect because a respiratory rate of 16/min is within normal range.
Choice D is incorrect because hyperglycemia is not a known adverse reaction to magnesium sulfate.
A nurse is caring for a client who has a placenta previa.
Which of the following findings should the nurse expect?
A. Painless, vaginal bleeding.
This is the most common symptom of placenta previa and can occur after 20 weeks of gestation.
B. Persistent headache.
Choice B is incorrect because a persistent headache is not a known symptom of placenta previa.
C. Uterine hypertonicity.
Choice C is incorrect because uterine hypertonicity is not a known symptom of placenta previa.
D. Firm, rigid abdomen.
Choice D is incorrect because a firm, rigid abdomen is not a known symptom of placenta previa.
Full Explanation
This is the most common symptom of placenta previa and can occur after 20 weeks of gestation.
Choice B is incorrect because a persistent headache is not a known symptom of placenta previa.
Choice C is incorrect because uterine hypertonicity is not a known symptom of placenta previa.
Choice D is incorrect because a firm, rigid abdomen is not a known symptom of placenta previa.