Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is providing teaching to a client about postpartum care. Which of the following information should the nurse include?
A. "You should begin performing Kegel exercises 6 to 7 weeks after delivery.".
The nurse should not include the information about beginning Kegel exercises 6 to 7 weeks after delivery because Kegel exercises are pelvic floor exercises that help improve bladder control and should be started earlier, immediately after childbirth. Delaying the exercises for 6 to 7 weeks could result in weaker pelvic floor muscles and potentially exacerbate postpartum urinary issues.
B. "You don't need to use birth control if you are exclusively breastfeeding.".
The nurse should not include the information that the client doesn't need to use birth control if exclusively breastfeeding. While exclusive breastfeeding can provide some natural contraceptive effect, it is not a reliable method, and there is still a risk of pregnancy during the postpartum period. The nurse should advise the client to use appropriate birth control methods to prevent unintended pregnancies.
C. "You can expect your breasts to be firm and tender 3 to 5 days after delivery.".
This is the correct answer. The nurse should include information about the client's breasts becoming firm and tender 3 to 5 days after delivery. This is a normal physiological response known as engorgement, which occurs as the breasts prepare for breastfeeding.
D. "Your bleeding will remain bright red for the next 6 to 8 weeks.".
The nurse should not inform the client that her bleeding will remain bright red for the next 6 to 8 weeks. While some postpartum bleeding is normal (known as lochia), the color and amount of bleeding change over time. Initially, it is bright red and gradually transitions to a lighter color over the following weeks.
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 include the information about beginning Kegel exercises 6 to 7 weeks after delivery because Kegel exercises are pelvic floor exercises that help improve bladder control and should be started earlier, immediately after childbirth. Delaying the exercises for 6 to 7 weeks could result in weaker pelvic floor muscles and potentially exacerbate postpartum urinary issues.
Choice B rationale:
The nurse should not include the information that the client doesn't need to use birth control if exclusively breastfeeding. While exclusive breastfeeding can provide some natural contraceptive effect, it is not a reliable method, and there is still a risk of pregnancy during the postpartum period. The nurse should advise the client to use appropriate birth control methods to prevent unintended pregnancies.
Choice C rationale:
This is the correct answer. The nurse should include information about the client's breasts becoming firm and tender 3 to 5 days after delivery. This is a normal physiological response known as engorgement, which occurs as the breasts prepare for breastfeeding.
Choice D rationale:
The nurse should not inform the client that her bleeding will remain bright red for the next 6 to 8 weeks. While some postpartum bleeding is normal (known as lochia), the color and amount of bleeding change over time. Initially, it is bright red and gradually transitions to a lighter color over the following weeks.
Similar Questions
A nurse in a provider's office is caring for a 20-year-old client who is at 12 weeks of gestation and requests an amniocentesis to determine the sex of the fetus. Which of the following responses should the nurse make?
A. "You cannot have an amniocentesis until you are at least 35 years of age.".
The nurse should not tell the client that she cannot have an amniocentesis until she is at least 35 years of age. Age is not the primary factor for determining the eligibility for an amniocentesis. Amniocentesis is typically performed when there is a medical indication, such as advanced maternal age, abnormal prenatal screening, or family history of genetic disorders.
B. "We can schedule the procedure for later today if you'd like.".
The nurse should not schedule the amniocentesis for later today without further clarification from the provider. Scheduling medical procedures without the provider's approval is not within the nurse's scope of practice and could lead to potential risks.
C. "This procedure determines if your baby has genetic or congenital disorders.".
This is the correct answer. The nurse should explain to the client that amniocentesis is a procedure used to determine if the baby has genetic or congenital disorders. It involves the extraction of a small amount of amniotic fluid to analyze the fetal cells for genetic abnormalities.
D. "Your provider will schedule a chorionic villus sampling to determine the sex of your baby.".
The nurse should not tell the client that her provider will schedule a chorionic villus sampling (CVS) to determine the sex of the baby. CVS is another prenatal diagnostic test, but its primary purpose is to detect genetic disorders early in pregnancy, not to determine the baby's sex.
Full Explanation
Choice A rationale:
The nurse should not tell the client that she cannot have an amniocentesis until she is at least 35 years of age. Age is not the primary factor for determining the eligibility for an amniocentesis. Amniocentesis is typically performed when there is a medical indication, such as advanced maternal age, abnormal prenatal screening, or a family history of genetic disorders.
Choice B rationale:
The nurse should not schedule the amniocentesis for later today without further clarification from the provider. Scheduling medical procedures without the provider's approval is not within the nurse's scope of practice and could lead to potential risks.
Choice C rationale:
This is the correct answer. The nurse should explain to the client that amniocentesis is a procedure used to determine if the baby has genetic or congenital disorders. It involves the extraction of a small amount of amniotic fluid to analyze the fetal cells for genetic abnormalities.
Choice D rationale:
The nurse should not tell the client that her provider will schedule a chorionic villus sampling (CVS) to determine the sex of the baby. CVS is another prenatal diagnostic test, but its primary purpose is to detect genetic disorders early in pregnancy, not to determine the baby's sex.
A nurse is assessing a newborn who is 4 hr old. Which of the following findings should the nurse identify as the priority to report to the provider?
A. Bluish discoloration of the hands and feet.
Bluish discoloration of the hands and feet (acrocyanosis) is common in newborns and usually resolves within the first few days of life. It is not typically a priority unless it persists or is accompanied by other signs of distress.
B. Overlapping of the cranial bones.
Overlapping of the cranial bones (craniosynostosis) requires monitoring but is not an immediate priority unless there are signs of increased intracranial pressure.
C. Forward and lateral positioning of the ears.
Forward and lateral positioning of the ears can be indicative of certain genetic conditions, such as Down syndrome. This finding is significant as it can signal the need for further evaluation and intervention to address any associated health concerns.
D. Small, distended white sebaceous glands on the face.
Small, distended white sebaceous glands on the face, known as milia, are common in newborns and are not a priority finding to report to the provider. They are benign and usually resolve on their own without treatment.
Full Explanation
The correct answer is Choice C.
Choice A rationale: Bluish discoloration of the hands and feet (acrocyanosis) is common in newborns and usually resolves within the first few days of life. It is not typically a priority unless it persists or is accompanied by other signs of distress.
Choice B rationale: Overlapping of the cranial bones (craniosynostosis) requires monitoring but is not an immediate priority unless there are signs of increased intracranial pressure.
Choice C rationale: Forward and lateral positioning of the ears can be indicative of certain genetic conditions, such as Down syndrome. This finding is significant as it can signal the need for further evaluation and intervention to address any associated health concerns.
Choice D rationale: Small, distended white sebaceous glands on the face (milia) are common in newborns and resolve on their own without intervention.
A nurse is caring for a client who is in active labor and is receiving oxytocin via IV infusion. The nurse has applied an internal fetal heart monitor and recognizes an early deceleration of the fetal heart rate tracing. Which of the following actions should the nurse take?
A. Continue to monitor the client.
Early decelerations are typically benign and are caused by fetal head compression during contractions. They usually do not require any specific intervention other than continued monitoring to ensure they remain early decelerations and do not progress to more concerning patterns.
B. Discontinue the oxytocin.
Discontinuing oxytocin is not necessary for early decelerations, as they are not indicative of fetal distress. Oxytocin would be discontinued if there were signs of more severe decelerations or other complications.
C. Assist the client to lay on her right side.
Assisting the client to lay on her right side is not specifically required for early decelerations. This position change is more commonly used for variable or late decelerations to improve uteroplacental blood flow.
D. Administer oxygen at 8 L/min per mask.
Administering oxygen at 8 L/min per mask is not needed for early decelerations. Oxygen is typically reserved for situations where there is evidence of fetal hypoxia or distress.
Full Explanation
The correct answer is choice A. Continue to monitor the client.
Choice A rationale:
Early decelerations are typically benign and are caused by fetal head compression during contractions. They usually do not require any specific intervention other than continued monitoring to ensure they remain early decelerations and do not progress to more concerning patterns.
Choice B rationale:
Discontinuing oxytocin is not necessary for early decelerations, as they are not indicative of fetal distress. Oxytocin would be discontinued if there were signs of more severe decelerations or other complications.
Choice C rationale:
Assisting the client to lay on her right side is not specifically required for early decelerations. This position change is more commonly used for variable or late decelerations to improve uteroplacental blood flow.
Choice D rationale:
Administering oxygen at 8 L/min per mask is not needed for early decelerations. Oxygen is typically reserved for situations where there is evidence of fetal hypoxia or distress.