Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which of the following statements by the client indicates a need for further teaching?
A. "I should keep my baby's head covered.”
Keeping the baby’s head covered helps to prevent heat loss, as newborns lose a significant amount of heat through their heads.
B. "My baby's bassinet should be kept away from fans and air conditioning.”
Keeping the baby’s bassinet away from fans and air conditioning helps to maintain a stable body temperature.
C. "My baby's temperature will be checked rectally every hour.”
Newborns’ temperatures are typically checked every 3 to 4 hours, not every hour, and are usually done axillary, not rectally.
D. "I should place my baby on my stomach and cover her with a warm blanket.”
Placing the baby on the mother’s stomach and covering her with a warm blanket promotes skin-to-skin contact and helps to maintain the baby’s body temperature.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Custom 2023 Fall NPRO 1100 Proctored Exam 3. Take the full exam now
Full Explanation
The correct answer is choice C.
Choice A rationale:
Keeping the baby’s head covered helps to prevent heat loss, as newborns lose a significant amount of heat through their heads.
Choice B rationale:
Keeping the baby’s bassinet away from fans and air conditioning helps to maintain a stable body temperature.
Choice C rationale:
Newborns’ temperatures are typically checked every 3 to 4 hours, not every hour, and are usually done axillary, not rectally.
Choice D rationale:
Placing the baby on the mother’s stomach and covering her with a warm blanket promotes skin-to-skin contact and helps to maintain the baby’s body temperature.
Similar Questions
A nurse is caring for a pregnant client in labor in a health care facility.
The nurse knows that which sign indicates that the patient is no longer in the first stage of labor?
A. Cervix dilation of 5 cm with 50% effacement.
Cervix dilation of 5 cm with 50% effacement is a sign of active phase of the first stage of labor, not the end of it.
B. Rupturing of fetal membranes.
Rupturing of fetal membranes can occur at any time during labor, not specifically at the end of the first stage.
C. Start of regular contractions.
Start of regular contractions is a sign of the onset of labor, not the end of the first stage.
D. Cervix dilation of 10 cm with 100% effacement.
Cervix dilation of 10 cm with 100% effacement indicates the end of the first stage of labor and the beginning of the second stage.
Full Explanation
The correct answer is choice D.
Choice A rationale:
Cervix dilation of 5 cm with 50% effacement is a sign of active phase of the first stage of labor, not the end of it.
Choice B rationale:
Rupturing of fetal membranes can occur at any time during labor, not specifically at the end of the first stage.
Choice C rationale:
Start of regular contractions is a sign of the onset of labor, not the end of the first stage.
Choice D rationale:
Cervix dilation of 10 cm with 100% effacement indicates the end of the first stage of labor and the beginning of the second stage.
A nurse is caring for a client who just delivered a newborn.
Following the delivery, which nursing action should be done first to care for the newborn?
A. Stimulate the infant to cry.
Stimulating the infant to cry is important, but it is not the first action to be taken.
B. Clear the respiratory tract.
Clearing the respiratory tract is the first action to be taken to ensure the newborn can breathe properly.
C. Dry the infant off and cover the head.
Drying the infant off and covering the head is done after the respiratory tract is cleared.
D. Cut the umbilical cord.
Cutting the umbilical cord is done after the infant is stabilized.
Full Explanation
The correct answer is choice B.
Choice A rationale:
Stimulating the infant to cry is important, but it is not the first action to be taken.
Choice B rationale:
Clearing the respiratory tract is the first action to be taken to ensure the newborn can breathe properly.
Choice C rationale:
Drying the infant off and covering the head is done after the respiratory tract is cleared.
Choice D rationale:
Cutting the umbilical cord is done after the infant is stabilized.
Which information would the nurse emphasize in the teaching plan for a postpartum woman who is reluctant to begin taking warm sitz baths?
A. Sitz baths cause perineal vasoconstriction and decreased bleeding.
Sitz baths cause perineal vasodilation, not vasoconstriction, and this does not directly affect bleeding.
B. The longer a sitz bath is continued, the more therapeutic it becomes.
The duration of a sitz bath does not necessarily correlate with its therapeutic effect.
C. Sitz baths increase the blood supply to the perineal area.
Sitz baths increase the blood supply to the perineal area, promoting healing and providing relief from discomfort.
D. Sitz baths may lead to increased postpartum infection.
Sitz baths do not increase the risk of postpartum infection when done properly.
Full Explanation
The correct answer is choice C.
Choice A rationale:
Sitz baths cause perineal vasodilation, not vasoconstriction, and this does not directly affect bleeding.
Choice B rationale:
The duration of a sitz bath does not necessarily correlate with its therapeutic effect.
Choice C rationale:
Sitz baths increase the blood supply to the perineal area, promoting healing and providing relief from discomfort.
Choice D rationale:
Sitz baths do not increase the risk of postpartum infection when done properly.