Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is providing care to a mother immediately following a stillbirth delivery.
Which of the following actions should the nurse take first?
A. Contact the health care facility's clergy.
Choice A is not an answer because contacting clergy is not the first action the nurse should take.
B. Assist the client with transferring to the gynecology unit.
Choice B is not an answer because transferring the client to another unit is not the first action the nurse should take.
C. Administer alprazolam 0.5 mg PO.
Choice C is not an answer because administering medication is not the first action the nurse should take.
D. Offer mother private time with the newborn.
The nurse should first offer the mother's private time with the newborn to allow her to grieve and say goodbye. This can be an important part of the healing process for the mother.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom SP23 N23 N240 Proctored Exam 3 Ch 11 24 32 43 44. Take the full exam now
Full Explanation
The nurse should first offer the mother's private time with the newborn to allow her to grieve and say goodbye.
This can be an important part of the healing process for the mother.
Choice A is not an answer because contacting clergy is not the first action the nurse should take.
Choice B is not an answer because transferring the client to another unit is not the first action the nurse should take.
Choice C is not an answer because administering medication is not the first action the nurse should take.
Similar Questions
A nurse is caring for a newborn whose mother voices concerns about sudden infant death syndrome (SIDS). The nurse should include which of the following statements in a discussion with the mother?
A. "SIDS is directly correlated with the diphtheria, tetanus, and pertussis vaccines.".
Choice A is not an answer because there is no direct correlation between SIDS and diphtheria, tetanus, and pertussis vaccines
B. "Sleep apnea is the main cause of SIDS.".
C. "Placing your child on her back when sleeping will decrease the risk of SIDS.".
The American Academy of Pediatrics recommends that infants be placed on their backs to sleep to reduce the risk of SIDS1.
D. "SIDS rates have been rising over the last 10 years.".
Full Explanation
The American Academy of Pediatrics recommends that infants be placed on their backs to sleep to reduce the risk of SIDS1.
Choice A is not an answer because there is no direct correlation between SIDS and diphtheria, tetanus, and pertussis vaccines
A nurse is assessing a child and notes several bruises. Which of the following actions should the nurse take?
A. Ask a psychiatrist to talk with the parents.
While involving mental health professionals can be part of a broader intervention plan, it is not the immediate priority in cases of suspected abuse. The nurse must first address the immediate safety concerns and follow the required reporting procedures.
B. Separate the child from the parents.
Separating the child from the parents without proper authority or immediate threat can escalate the situation and may not be legally permissible. This action should be taken by authorities with the legal power to do so if deemed necessary.
C. Report the suspected abuse to the authorities.
Nurses are mandated reporters, which means they are legally required to report any suspected child abuse to the appropriate authorities immediately. This action ensures that the child’s safety is prioritized and that a proper investigation can be initiated however, obtaining a detailed history is the priority.
D. Obtain a detailed history.
When a nurse observes several bruises on a child, the initial action should be to obtain a detailed history. This step allows the nurse to gather information about the circumstances surrounding the bruises, assess for any potential signs of abuse, and determine the most appropriate course of action.
Full Explanation
a. While involving mental health professionals can be part of a broader intervention plan, it is not the immediate priority in cases of suspected abuse. The nurse must first address the immediate safety concerns and follow the required reporting procedures.
b. Separating the child from the parents without proper authority or immediate threat can escalate the situation and may not be legally permissible. This action should be taken by authorities with the legal power to do so if deemed necessary.
c. Nurses are mandated reporters, which means they are legally required to report any suspected child abuse to the appropriate authorities immediately. This action ensures that the child’s safety is prioritized and that a proper investigation can be initiated however, obtaining a detailed history is the priority.
d. When a nurse observes several bruises on a child, the initial action should be to obtain a detailed history. This step allows the nurse to gather information about the circumstances surrounding the bruises, assess for any potential signs of abuse, and determine the most appropriate course of action.
A nurse is caring for an infant in a provider's office.
Medical History Provider Visit #1. Heart rate 144/min.
Axillary temperature 39.7° C (103.5°F). Respiratory rate 32/min.
Oxygen saturation 95% on room air. Provider Visit #2 (4 days later).
Axillary temperature 37.4° C (99.3° F). Heart rate 132/min.
Respiratory rate 28/min.
Oxygen saturation 97% on room air.
Which of the following actions should the nurse plan to take? Select the actions the nurse should plan to take.
A. Teach caregivers to change diapers when wet.
Frequent diaper changes are a standard practice to prevent diaper rash and skin irritation, which is particularly important in infants, regardless of the presence of diarrhea or other symptoms. Wet diapers can cause skin breakdown, especially in the context of illness, where skin may be more vulnerable. This is a proactive, preventive measure that aligns with general infant care.
B. Have caregivers administer 16 oz of water after each diarrhea stool.
The medical history does not mention diarrhea, so this action assumes a condition not supported by the data. Administering 16 oz of water per diarrhea stool is excessive for an infant, as it could lead to fluid overload or electrolyte imbalances. Infants typically require smaller, calculated fluid volumes (e.g., oral rehydration solutions) based on weight and clinical status if diarrhea is present. Without evidence of diarrhea, this action is not indicated.
C. Cleanse the diaper area with soap and water.
Cleansing the diaper area with mild soap and water is a standard nursing intervention to maintain skin integrity. It removes irritants and bacteria effectively, reducing the risk of developing a secondary diaper dermatitis.
D. Collect nasal drainage for culture and sensitivity.
Only done if ordered and if infection is suspected. At follow-up (Visit #2), infant is afebrile and stable—no need for culture.
F. Teach caregivers to apply talcum powder to creases.
Talcum powder is not recommended for infants due to the risk of inhalation, which can cause respiratory issues, especially in an infant with a recent respiratory illness. Modern pediatric guidelines favor keeping skin dry and using barrier creams (e.g., zinc oxide) if needed, rather than talcum powder, to prevent irritation in skin creases.
G. Use a nasal aspirator after feedings.
Using a nasal aspirator should be done before feedings, not after. Suctioning after a feeding can trigger the gag reflex and cause the infant to vomit, increasing the risk of aspiration.
Full Explanation
Choice A rationale: Teaching caregivers to change diapers immediately when wet is essential for preventing skin breakdown and secondary infections, especially when an infant has been experiencing high fevers or potential gastrointestinal distress.
Choice B rationale: Administering 16 oz of water to an infant after each stool is dangerous. Infants are at high risk for water intoxication and electrolyte imbalances; rehydration should involve breast milk, formula, or oral rehydration solutions.
Choice C rationale: Cleansing the diaper area with mild soap and water is a standard nursing intervention to maintain skin integrity. It removes irritants and bacteria effectively, reducing the risk of developing a secondary diaper dermatitis.
Choice D rationale: Collecting nasal drainage for culture is not indicated based on the provided vital signs. The infant's temperature has improved, and there is no specific evidence of a worsening respiratory infection requiring a culture.
Choice F rationale: Caregivers should never apply talcum powder to an infant’s skin creases. Talcum powder poses a significant aspiration risk and can lead to severe respiratory distress or chronic lung irritation if inhaled.
Choice G rationale: Using a nasal aspirator should be done before feedings, not after. Suctioning after a feeding can trigger the gag reflex and cause the infant to vomit, increasing the risk of aspiration.