Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A. Place the newborn in Trendelenburg position.
Placing the newborn in Trendelenburg position is not an appropriate nursing action, as it can cause increased intracranial pressure, decreased lung expansion, and aspiration. The nurse should position the newborn in a neutral or slightly elevated head position, with the neck slightly extended.
B. Maintain oxygen saturations between 93% to 95%.
Maintaining oxygen saturations between 93% to 95% is an appropriate nursing action, as it ensures adequate oxygen delivery to the tissues and organs, while avoiding hyperoxia or hypoxia, which can cause complications, such as retinopathy of prematurity, intraventricular hemorrhage, or necrotizing enterocolitis.
C. Insert an orogastric tube for decompression of the stomach.
Inserting an orogastric tube for decompression of the stomach is not an appropriate nursing action, as it is not indicated for oxygen hood therapy, unless the newborn has abdominal distension, vomiting, or feeding intolerance. The nurse should monitor the newborn's abdominal girth, bowel sounds, and feeding tolerance, and report any signs of gastrointestinal dysfunction.
D. Remove the hood every hour for 10 min to facilitate bonding.
Removing the hood every hour for 10 min to facilitate bonding is not an appropriate nursing action, as it can cause fluctuations in the oxygen concentration and temperature, and increase the risk of infection. The nurse should maintain the hood in place, and encourage the parents to touch, talk, and sing to the newborn, and provide skin-to-skin contact when possible.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Maternal Newborn Proctored Exam 4. Take the full exam now
Full Explanation
Choice A reason: Placing the newborn in Trendelenburg position is not an appropriate nursing action, as it can cause increased intracranial pressure, decreased lung expansion, and aspiration. The nurse should position the newborn in a neutral or slightly elevated head position, with the neck slightly extended.
Choice B reason: Maintaining oxygen saturations between 93% to 95% is an appropriate nursing action, as it ensures adequate oxygen delivery to the tissues and organs, while avoiding hyperoxia or hypoxia, which can cause complications, such as retinopathy of prematurity, intraventricular hemorrhage, or necrotizing enterocolitis.
Choice C reason: Inserting an orogastric tube for decompression of the stomach is not an appropriate nursing action, as it is not indicated for oxygen hood therapy, unless the newborn has abdominal distension, vomiting, or feeding intolerance. The nurse should monitor the newborn's abdominal girth, bowel sounds, and feeding tolerance, and report any signs of gastrointestinal dysfunction.
Choice D reason: Removing the hood every hour for 10 min to facilitate bonding is not an appropriate nursing action, as it can cause fluctuations in the oxygen concentration and temperature, and increase the risk of infection. The nurse should maintain the hood in place, and encourage the parents to touch, talk, and sing to the newborn, and provide skin-to-skin contact when possible.
Similar Questions
A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take?
A. Monitor the newborn's blood pressure.
Monitoring the newborn's blood pressure is not the most appropriate action, as it is not directly related to the signs of diaphoresis, jitteriness, and lethargy. These signs are more indicative of hypoglycemia, which is a low blood sugar level that can affect newborns, especially those who are premature, small for gestational age, or have diabetic mothers.
B. Initiate phototherapy.
Initiating phototherapy is not the most appropriate action, as it is used to treat hyperbilirubinemia, which is a high level of bilirubin in the blood that can cause jaundice, a yellowish discoloration of the skin and eyes. Hyperbilirubinemia does not cause diaphoresis, jitteriness, or lethargy.
C. Obtain blood glucose by heel stick.
Obtaining blood glucose by heel stick is the most appropriate action, as it can confirm the diagnosis of hypoglycemia, which is the most likely cause of the signs of diaphoresis, jitteriness, and lethargy. The nurse should perform a heel stick using a sterile lancet and a glucose meter, and obtain a blood sample from the lateral aspect of the heel. The nurse should also provide warmth, stimulation, and feeding to the newborn, and report the blood glucose level to the provider.
D. Place the newborn in a radiant warmer.
Placing the newborn in a radiant warmer is not the most appropriate action, as it can cause dehydration, fluid loss, and further hypoglycemia. The nurse should use a radiant warmer only if the newborn is hypothermic, which is a low body temperature that can also affect newborns. The nurse should monitor the newborn's temperature and skin color, and adjust the warmer accordingly.
Full Explanation
Choice A reason: Monitoring the newborn's blood pressure is not the most appropriate action, as it is not directly related to the signs of diaphoresis, jitteriness, and lethargy. These signs are more indicative of hypoglycemia, which is a low blood sugar level that can affect newborns, especially those who are premature, small for gestational age, or have diabetic mothers.
Choice B reason: Initiating phototherapy is not the most appropriate action, as it is used to treat hyperbilirubinemia, which is a high level of bilirubin in the blood that can cause jaundice, a yellowish discoloration of the skin and eyes. Hyperbilirubinemia does not cause diaphoresis, jitteriness, or lethargy.
Choice C reason: Obtaining blood glucose by heel stick is the most appropriate action, as it can confirm the diagnosis of hypoglycemia, which is the most likely cause of the signs of diaphoresis, jitteriness, and lethargy. The nurse should perform a heel stick using a sterile lancet and a glucose meter, and obtain a blood sample from the lateral aspect of the heel. The nurse should also provide warmth, stimulation, and feeding to the newborn, and report the blood glucose level to the provider.
Choice D reason: Placing the newborn in a radiant warmer is not the most appropriate action, as it can cause dehydration, fluid loss, and further hypoglycemia. The nurse should use a radiant warmer only if the newborn is hypothermic, which is a low body temperature that can also affect newborns. The nurse should monitor the newborn's temperature and skin color, and adjust the warmer accordingly.
A nurse receives report about assigned clients at the start of the shift. Which of the following clients should the nurse plan to see first?
A. A client who experienced a cesarean birth 4 hr ago and reports severe pain.
This client should be seen first, as she has the most urgent and acute problem that requires immediate assessment and intervention. Severe pain after a cesarean birth can indicate infection, hemorrhage, or wound dehiscence, which are serious complications that can affect the client's recovery and well-being. The nurse should evaluate the client's pain level, location, and characteristics, and administer analgesics as prescribed. The nurse should also inspect the incision site, monitor the vital signs and lochia, and provide comfort measures.
B. A client who has preeclampsia with a BP of 128/80 mm Hg
This client should be seen second, as she has a chronic and stable problem that requires ongoing monitoring and management. Preeclampsia is a hypertensive disorder of pregnancy that can cause complications, such as eclampsia, HELLP syndrome, or placental abruption. However, this client has a mild elevation of blood pressure that does not indicate severe preeclampsia or imminent eclampsia. The nurse should check the client's urine protein, reflexes, and edema, and report any signs of worsening condition to the provider.
C. A client who is scheduled for discharge following a vaginal delivery without complications.
This client should be seen third, as she has a normal and expected outcome that requires routine education and discharge planning. A vaginal delivery without complications does not pose any significant risk or concern for the client or the newborn. The nurse should review the discharge instructions, such as follow-up appointments, self-care, breastfeeding, and warning signs, and answer any questions that the client may have.
D. A client who experienced a vaginal birth 24 hr ago and reports a scant amount of lochia.
This client should be seen last, as she has a common and benign finding that requires reassurance and documentation. A scant amount of lochia after a vaginal birth is normal and expected, as it reflects the healing and involution of the uterus. The nurse should assess the color, odor, and consistency of the lochia, and provide perineal care and hygiene education to the client.
Full Explanation
Choice A reason: This client should be seen first, as she has the most urgent and acute problem that requires immediate assessment and intervention. Severe pain after a cesarean birth can indicate infection, hemorrhage, or wound dehiscence, which are serious complications that can affect the client's recovery and well-being. The nurse should evaluate the client's pain level, location, and characteristics, and administer analgesics as prescribed. The nurse should also inspect the incision site, monitor the vital signs and lochia, and provide comfort measures.
Choice B reason: This client should be seen second, as she has a chronic and stable problem that requires ongoing monitoring and management. Preeclampsia is a hypertensive disorder of pregnancy that can cause complications, such as eclampsia, HELLP syndrome, or placental abruption. However, this client has a mild elevation of blood pressure that does not indicate severe preeclampsia or imminent eclampsia. The nurse should check the client's urine protein, reflexes, and edema, and report any signs of worsening condition to the provider.
Choice C reason: This client should be seen third, as she has a normal and expected outcome that requires routine education and discharge planning. A vaginal delivery without complications does not pose any significant risk or concern for the client or the newborn. The nurse should review the discharge instructions, such as follow-up appointments, self-care, breastfeeding, and warning signs, and answer any questions that the client may have.
Choice D reason: This client should be seen last, as she has a common and benign finding that requires reassurance and documentation. A scant amount of lochia after a vaginal birth is normal and expected, as it reflects the healing and involution of the uterus. The nurse should assess the color, odor, and consistency of the lochia, and provide perineal care and hygiene education to the client.
Which client is at greatest risk for early postpartum hemorrhage (PPH)?
A. Primigravida in spontaneous labor with preterm twins
Primigravida in spontaneous labor with preterm twins is not at the greatest risk for early postpartum hemorrhage, as preterm births are associated with lower blood loss and smaller placentas. However, this client may have other complications, such as preterm labor, premature rupture of membranes, or fetal growth restriction.
B. Primiparous woman (G 2, P 1-0-0-1) being prepared for an emergency cesarean birth for fetal distress
Primiparous woman (G 2, P 1-0-0-1) being prepared for an emergency cesarean birth for fetal distress is not at the greatest risk for early postpartum hemorrhage, as cesarean births are associated with higher blood loss and larger incisions. However, this client may have other complications, such as infection, wound dehiscence, or thromboembolism.
C. Multiparous woman (G 3, P 2-0-0-2) with an 8-hour labor
Multiparous woman (G 3, P 2-0-0-2) with an 8-hour labor is at the greatest risk for early postpartum hemorrhage, as multiparity and rapid labor are both risk factors for uterine atony, which is the most common cause of early postpartum hemorrhage. Uterine atony is a condition where the uterus fails to contract and retract after delivery, and can cause excessive bleeding and hypovolemic shock.
D. Woman with severe preeclampsia on magnesium sulfate whose labor is being induced
Woman with severe preeclampsia on magnesium sulfate whose labor is being induced is not at the greatest risk for early postpartum hemorrhage, as preeclampsia and magnesium sulfate are both risk factors for late postpartum hemorrhage, which occurs after 24 hours of delivery. However, this client may have other complications, such as eclampsia, HELLP syndrome, or placental abruption.
Full Explanation
Choice A reason: Primigravida in spontaneous labor with preterm twins is not at the greatest risk for early postpartum hemorrhage, as preterm births are associated with lower blood loss and smaller placentas. However, this client may have other complications, such as preterm labor, premature rupture of membranes, or fetal growth restriction.
Choice B reason: Primiparous woman (G 2, P 1-0-0-1) being prepared for an emergency cesarean birth for fetal distress is not at the greatest risk for early postpartum hemorrhage, as cesarean births are associated with higher blood loss and larger incisions. However, this client may have other complications, such as infection, wound dehiscence, or thromboembolism.
Choice C reason: Multiparous woman (G 3, P 2-0-0-2) with an 8-hour labor is at the greatest risk for early postpartum hemorrhage, as multiparity and rapid labor are both risk factors for uterine atony, which is the most common cause of early postpartum hemorrhage. Uterine atony is a condition where the uterus fails to contract and retract after delivery, and can cause excessive bleeding and hypovolemic shock.
Choice D reason: Woman with severe preeclampsia on magnesium sulfate whose labor is being induced is not at the greatest risk for early postpartum hemorrhage, as preeclampsia and magnesium sulfate are both risk factors for late postpartum hemorrhage, which occurs after 24 hours of delivery. However, this client may have other complications, such as eclampsia, HELLP syndrome, or placental abruption.