Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include?
A. Offer the newborn 30 mL (1 oz) of water between feedings.
Newborns who are exclusively breastfed do not require additional water between feedings. Breast milk provides all the necessary fluids to keep the baby hydrated.
B. Allow the baby to feed at least every 3 hr.
This instruction is generally appropriate. Newborns typically need to breastfeed frequently, usually at least every 2-3 hours, to ensure they receive adequate nutrition and to stimulate milk production in the mother. Therefore, this instruction should be included.
C. Feed the newborn 5 to 10 min per breast.
Newborns should be allowed to nurse on one breast until they are satisfied and then offered the other breast. Restricting feeding to a specific duration (5 to 10 minutes) on each breast may interfere with adequate feeding and hinder milk production.
D. Expect two to four wet diapers every 24 hr.
This instruction is generally appropriate. Monitoring the frequency of wet diapers is an essential way to assess whether the newborn is adequately hydrated and receiving enough breast milk. Generally, newborns should have at least six wet diapers a day, which indicates adequate fluid intake.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Maternal Newborn 2019 NGN Proctored Exam. Take the full exam now
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-stained urine is typically due to urate crystals and is common in newborns. It usually resolves on its own and is not a cause for concern.
B. Single palmar creases.
Single palmar creases can be associated with certain genetic conditions, such as Down syndrome. This finding should be reported to the provider for further evaluation.
C. Subconjunctival hemorrhage.
Subconjunctival hemorrhage is a common finding in newborns due to the pressure changes during delivery. It usually resolves without intervention and is not typically a cause for concern.
D. Transient circumoral cyanosis.
Transient circumoral cyanosis is often seen in newborns and can occur when the baby is crying or feeding. It usually resolves on its own and is not typically a cause for concern.
Full Explanation
The correct answer is choice B. Single palmar creases.
Choice A rationale:
Rust-stained urine is typically due to urate crystals and is common in newborns. It usually resolves on its own and is not a cause for concern.
Choice B rationale:
Single palmar creases can be associated with certain genetic conditions, such as Down syndrome. This finding should be reported to the provider for further evaluation.
Choice C rationale:
Subconjunctival hemorrhage is a common finding in newborns due to the pressure changes during delivery. It usually resolves without intervention and is not typically a cause for concern.
Choice D rationale:
Transient circumoral cyanosis is often seen in newborns and can occur when the baby is crying or feeding. It usually resolves on its own and is not typically a cause for concern.
A nurse in a clinic is caring for a client who is in her second trimester of pregnancy. The client expresses concern about preparing her 2-year-old child for a new sibling. Which of the following is an appropriate response by the nurse?
A. "Move your toddler to his new bed 2 months before the baby comes home.".
The nurse should not advise the client to "Move your toddler to his new bed 2 months before the baby comes home.”. This can disrupt the toddler's routine and create unnecessary stress during a significant transition in their life.
B. "Avoid bringing your toddler to prenatal visits.".
It is not appropriate to "Avoid bringing your toddler to prenatal visits.”. Involving the toddler in prenatal visits can help them adjust to the idea of a new sibling and reduce potential jealousy or feelings of being excluded.
C. "Let your toddler see you carrying the baby into the home for the first time.".
The correct answer is to "Let your toddler see you carrying the baby into the home for the first time.”. This approach allows the toddler to witness the arrival of the new sibling and can help them feel involved and excited about the new addition to the family.
D. "Require scheduled interactions between the toddler and the baby.".
"Require scheduled interactions between the toddler and the baby”. is not the best response. While it's essential to facilitate interactions between the toddler and the baby, forcing scheduled interactions may cause stress and resistance, especially if the toddler is not ready for such encounters.
Full Explanation
Choice A rationale:
The nurse should not advise the client to "Move your toddler to his new bed 2 months before the baby comes home.”. This can disrupt the toddler's routine and create unnecessary stress during a significant transition in their life.
Choice B rationale:
It is not appropriate to "Avoid bringing your toddler to prenatal visits.”. Involving the toddler in prenatal visits can help them adjust to the idea of a new sibling and reduce potential jealousy or feelings of being excluded.
Choice C rationale:
The correct answer is to "Let your toddler see you carrying the baby into the home for the first time.”. This approach allows the toddler to witness the arrival of the new sibling and can help them feel involved and excited about the new addition to the family.
Choice D rationale:
"Require scheduled interactions between the toddler and the baby”. is not the best response. While it's essential to facilitate interactions between the toddler and the baby, forcing scheduled interactions may cause stress and resistance, especially if the toddler is not ready for such encounters.
A nurse is teaching a newly licensed nurse about the uses of ultrasonography in the first trimester of pregnancy. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
A. "Ultrasound is used to determine gestational age in the first trimester.".
Determining gestational age in the first trimester is a common and important use of ultrasound. It helps confirm the estimated due date and monitor the fetus's growth and development.
B. "Ultrasound is used to perform a biophysical profile in the first trimester.".
Performing a biophysical profile in the first trimester is not a common use of ultrasound. Biophysical profiles are usually performed in the second or third trimester to assess fetal well-being.
C. "Ultrasound is used to observe for placental maturity in the first trimester.".
Observing placental maturity in the first trimester is not a standard use of ultrasound. Placental maturity is typically assessed later in pregnancy, especially in the third trimester.
D. "Ultrasound is used to detect intrauterine growth restriction in the first trimester.".
Detecting intrauterine growth restriction in the first trimester is not a primary use of ultrasound. Intrauterine growth restriction is more commonly assessed in later stages of pregnancy when fetal growth is a concern.
Full Explanation
Choice A rationale:
Determining gestational age in the first trimester is a common and important use of ultrasound. It helps confirm the estimated due date and monitor the fetus's growth and development.
Choice B rationale:
Performing a biophysical profile in the first trimester is not a common use of ultrasound. Biophysical profiles are usually performed in the second or third trimester to assess fetal well-being.
Choice C rationale:
Observing placental maturity in the first trimester is not a standard use of ultrasound. Placental maturity is typically assessed later in pregnancy, especially in the third trimester.
Choice D rationale:
Detecting intrauterine growth restriction in the first trimester is not a primary use of ultrasound. Intrauterine growth restriction is more commonly assessed in the later stages of pregnancy when fetal growth is a concern.