Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan?
A. Apply a thin layer of lotion to the newborn's skin every 4 hr.
The nurse should not apply lotion to the newborn's skin during phototherapy. Phototherapy involves exposing the newborn's skin to light to treat jaundice by breaking down bilirubin. Applying lotion may interfere with the effectiveness of the therapy and may not be recommended as it can make it difficult for the skin to release heat generated during the process.
B. Give the newborn 1 oz of glucose water every 4 hr.
Giving the newborn glucose water every 4 hours is not a necessary action during phototherapy. The primary concern during phototherapy is to treat jaundice, and giving glucose water may not have a direct impact on the effectiveness of the treatment. Additionally, it is important to focus on monitoring the newborn's bilirubin levels and hydration status.
C. Ensure the newborn's eyes are closed beneath the shield.
Ensure the newborn's eyes are closed beneath the shield.
D. Dress the newborn in a thin layer of clothing during therapy.
Dressing the newborn in a thin layer of clothing during phototherapy is not recommended. Phototherapy works best when the newborn's skin is exposed to the light source, and covering the skin with clothing may decrease the effectiveness of the treatment.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Maternal Newborn 2019 NGN Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
The nurse should not apply lotion to the newborn's skin during phototherapy. Phototherapy involves exposing the newborn's skin to light to treat jaundice by breaking down bilirubin. Applying lotion may interfere with the effectiveness of the therapy and may not be recommended as it can make it difficult for the skin to release heat generated during the process.
Choice B rationale:
Giving the newborn glucose water every 4 hours is not a necessary action during phototherapy. The primary concern during phototherapy is to treat jaundice, and giving glucose water may not have a direct impact on the effectiveness of the treatment. Additionally, it is important to focus on monitoring the newborn's bilirubin levels and hydration status.
Choice D rationale:
Dressing the newborn in a thin layer of clothing during phototherapy is not recommended. Phototherapy works best when the newborn's skin is exposed to a light source, and covering the skin with clothing may decrease the effectiveness of the treatment.
Similar Questions
A nurse is assessing a client who has preeclampsia during a prenatal visit. Which of the following findings should the nurse report to the provider?
A. Blood glucose 110 mg/dL.
A blood glucose level of 110 mg/dL is within the normal range for a non-pregnant individual. During pregnancy, the target range for blood glucose levels may vary, but 110 mg/dL does not typically raise concerns for preeclampsia.
B. Urine protein of 3+.
Urine protein of 3+
C. Hemoglobin 13 g/dL.
A hemoglobin level of 13 g/dL is within the normal range for a pregnant woman. While hemoglobin levels are important to monitor during pregnancy, this value alone does not indicate a significant concern related to preeclampsia.
D. Deep tendon reflexes of 2+.
Deep tendon reflexes (DTR) of 2+ are within the normal range. Higher DTR levels may be concerning, but a 2+ rating is normal and does not raise immediate alarm for preeclampsia.
Full Explanation
Choice A rationale:
A blood glucose level of 110 mg/dL is within the normal range for a non-pregnant individual. During pregnancy, the target range for blood glucose levels may vary, but 110 mg/dL does not typically raise concerns for preeclampsia.
Choice C rationale:
A haemoglobin level of 13 g/dL is within the normal range for a pregnant woman. While haemoglobin levels are important to monitor during pregnancy, this value alone does not indicate a significant concern related to preeclampsia.
Choice D rationale:
Deep tendon reflexes (DTR) of 2+ are within the normal range. Higher DTR levels may be concerning, but a 2+ rating is normal and does not raise immediate alarm for preeclampsia.
A nurse is monitoring a client who is undergoing a nonstress test at 35 weeks of gestation. Which of the following findings requires intervention by the nurse?
A. An FHR that peaks 20 beats above the baseline.
A non-stress test (NST) is supposed to assess fetal well-being by looking for accelerations in the fetal heart rate (FHR) in response to fetal movement. An FHR that peaks 20 beats above the baseline is a desirable finding in an NST, indicating good fetal reactivity.
B. Three uterine contractions within a 20-min period.
While not typical during a standard NST, three uterine contractions within a 20-minute period might not necessarily require immediate intervention. However, the nurse should document it and notify the healthcare provider for further assessment, especially if the contractions are causing discomfort or if there are other concerning signs.
C. One acceleration of the FHR within a 20-min period.
A single acceleration of the FHR within a 20-minute NST is considered non-reactive and may indicate fetal compromise. This finding requires further investigation by the healthcare provider, potentially including additional monitoring or interventions.
D. Uterine contractions lasting 20 to 30 seconds each.
Uterine contractions lasting 20 to 30 seconds each are not a typical finding during an NST, but they may not necessarily be a cause for immediate concern unless they are causing the client pain or are accompanied by other concerning signs. The nurse should document the contractions and notify the healthcare provider.
Full Explanation
The correct answer is choice c. One acceleration of the FHR within a 20-min period.
Here's the rationale for each choice:
Choice A: Rationale: A non-stress test (NST) is supposed to assess fetal well-being by looking for accelerations in the fetal heart rate (FHR) in response to fetal movement. An FHR that peaks 20 beats above the baseline is a desirable finding in an NST, indicating good fetal reactivity.
Choice B: Rationale: While not typical during a standard NST, three uterine contractions within a 20-minute period might not necessarily require immediate intervention. However, the nurse should document it and notify the healthcare provider for further assessment, especially if the contractions are causing discomfort or if there are other concerning signs.
Choice C: Rationale: A single acceleration of the FHR within a 20-minute NST is considered non-reactive and may indicate fetal compromise. This finding requires further investigation by the healthcare provider, potentially including additional monitoring or interventions.
Choice D: Rationale: Uterine contractions lasting 20 to 30 seconds each are not a typical finding during an NST, but they may not necessarily be a cause for immediate concern unless they are causing the client pain or are accompanied by other concerning signs. The nurse should document the contractions and notify the healthcare provider.
A nurse is reviewing the laboratory report for a client who is in active labor. The client tested positive for group B streptococcus B-hemolytic. Which of the following medications should the nurse plan to administer to the client?
A. Doxycycline.
Rationale against: Poor penetration into amniotic fluid:Doxycycline does not effectively reach the amniotic sac,where the baby is surrounded,and therefore may not adequately protect the newborn from GBS infection. Adverse effects in newborns:Doxycycline can cause tooth discoloration and bone development problems in infants exposed in utero.
B. Cefotetan.
Rationale for: Alternative for penicillin allergy:Cefotetan is a cephalosporin antibiotic effective against GBS and can be used in women with penicillin allergy. Rationale against: Second-line option:Ampicillin is the preferred choice due to its lower cost and broader spectrum of activity against GBS strains.
C. Ampicillin.
Rationale: Group B Streptococcus (GBS) B-hemolyticis a bacterium that can colonize the vagina and rectum of pregnant women.While usually harmless to the mother,it can be passed to the newborn during birth and cause serious infections,including pneumonia,meningitis,and sepsis. Ampicillinis thefirst-line antibioticrecommended by the Centers for Disease Control and Prevention (CDC) for theprevention of GBS disease in newborns.It belongs to thepenicillin classof antibiotics,which are highly effective against GBS and generally well-tolerated by pregnant women and newborns. Rationale for: First-line antibiotic:Ampicillin is the CDC-recommended first-line antibiotic for GBS prophylaxis due to its: High effectiveness against GBS:Ampicillin has a broad spectrum of activity against GBS strains. Good safety profile:Ampicillin is generally well-tolerated by pregnant women and newborns. Cost-effectiveness:Ampicillin is a relatively inexpensive antibiotic compared to other options. Doxycyclineis not recommended for GBS prophylaxis due to its poor penetration into amniotic fluid and potential for causing tooth discoloration and bone development problems in newborns. Cefotetanis an alternative option for women with penicillin allergy,but ampicillin is still preferred due to its lower cost and broader spectrum of activity against GBS strains. Fluconazoleis an antifungal medication and has no activity against GBS bacteria.
D. Fluconazole.
Rationale against: Antifungal medication:Fluconazole is an antifungal medication and has no activity against GBS,which is a bacterium.
Full Explanation
The correct answer is c. Ampicillin.
Rationale:
- Group B Streptococcus (GBS) B-hemolytic is a bacterium that can colonize the vagina and rectum of pregnant women. While usually harmless to the mother, it can be passed to the newborn during birth and cause serious infections, including pneumonia, meningitis, and sepsis.
- Ampicillin is the first-line antibiotic recommended by the Centers for Disease Control and Prevention (CDC) for the prevention of GBS disease in newborns. It belongs to the penicillin class of antibiotics, which are highly effective against GBS and generally well-tolerated by pregnant women and newborns.
- Doxycycline is not recommended for GBS prophylaxis due to its poor penetration into amniotic fluid and potential for causing tooth discoloration and bone development problems in newborns.
- Cefotetan is an alternative option for women with penicillin allergy, but ampicillin is still preferred due to its lower cost and broader spectrum of activity against GBS strains.
- Fluconazole is an antifungal medication and has no activity against GBS bacteria.
Detailed Rationale for Each Choice:
a. Doxycycline:
- Rationale against:
- Poor penetration into amniotic fluid: Doxycycline does not effectively reach the amniotic sac, where the baby is surrounded, and therefore may not adequately protect the newborn from GBS infection.
- Adverse effects in newborns: Doxycycline can cause tooth discoloration and bone development problems in infants exposed in utero.
b. Cefotetan:
- Rationale for:
- Alternative for penicillin allergy: Cefotetan is a cephalosporin antibiotic effective against GBS and can be used in women with penicillin allergy.
- Rationale against:
- Second-line option: Ampicillin is the preferred choice due to its lower cost and broader spectrum of activity against GBS strains.
c. Ampicillin:
- Rationale for:
- First-line antibiotic: Ampicillin is the CDC-recommended first-line antibiotic for GBS prophylaxis due to its:
- High effectiveness against GBS: Ampicillin has a broad spectrum of activity against GBS strains.
- Good safety profile: Ampicillin is generally well-tolerated by pregnant women and newborns.
- Cost-effectiveness: Ampicillin is a relatively inexpensive antibiotic compared to other options.
- First-line antibiotic: Ampicillin is the CDC-recommended first-line antibiotic for GBS prophylaxis due to its:
d. Fluconazole:
- Rationale against:
- Antifungal medication: Fluconazole is an antifungal medication and has no activity against GBS, which is a bacterium.