Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reinforcing discharging teaching with a client who is 2 days postpartum. Which of the following statements should the nurse include in the teaching?
A. "If you give formula to your newborn, expect at least one stool every 3 days.".
This is incorrect because formula-fed newborns typically have one or more stools per day, not every 3 days. Stooling less frequently than once a day may indicate constipation.
B. "If you breastfeed your newborn, expect two to three stools per day.".
This is correct because breastfed newborns usually have two to three stools per day, which are soft and yellow. Breastfed babies may also have stools less frequently, even once every 10-14 days, as long as the stool is soft.
C. "You should feed your newborn formula every 2 hours.".
This is incorrect because newborns should be fed formula on demand, not on a strict schedule. The average feeding interval for formula-fed newborns is about 3 to 4 hours.
D. "You should breastfeed your newborn five to seven times each day.".
This is incorrect because newborns should be breastfed eight to 12 times per day, not five to seven times. Breastfeeding more frequently helps to establish milk supply and prevent engorgement. - Stanford Medicine.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom Maternity Final 23D Proctored Exam. Take the full exam now
Full Explanation
Choice A reason:
This is incorrect because formula-fed newborns typically have one or more stools per day, not every 3 days. Stooling less frequently than once a day may indicate constipation.
Choice B reason:
This is correct because breastfed newborns usually have two to three stools per day, which are soft and yellow. Breastfed babies may also have stools less frequently, even once every 10-14 days, as long as the stool is soft.
Choice C reason:
This is incorrect because newborns should be fed formula on demand, not on a strict schedule. The average feeding interval for formula-fed newborns is about 3 to 4 hours.
Choice D reason:
This is incorrect because newborns should be breastfed eight to 12 times per day, not five to seven times. Breastfeeding more frequently helps to establish milk supply and prevent engorgement. - Stanford Medicine.
Similar Questions
A nurse is explaining TTN to the newborn's mother. Which statement indicates that the mother understands the teaching?
A. "My baby might be in the NICU for 2 weeks.".
This is incorrect because TTN usually resolves within 24 to 72 hours of birth and does not require a long stay in the NICU.
B. "This breathing problem might have happened because I had a cesarean birth.".
This is correct because TTN is more common in babies born by cesarean section without labor, as they do not have the hormonal changes that help clear the fetal lung fluid.
C. "I cannot breastfeed my baby while he is breathing so fast.".
This is incorrect because breastfeeding is not contraindicated in babies with TTN, unless they have severe respiratory distress or need continuous positive airway pressure (CPAP) support.
D. "My baby will probably go home on oxygen therapy.".
This is incorrect because TTN does not cause chronic lung disease or require oxygen therapy at home. Most babies with TTN only need supplemental oxygen for a few days until their breathing improves.
Full Explanation
Choice A reason:
This is incorrect because TTN usually resolves within 24 to 72 hours of birth and does not require a long stay in the NICU.
Choice B reason:
This is correct because TTN is more common in babies born by cesarean section without labor, as they do not have the hormonal changes that help clear the fetal lung fluid.
Choice C reason:
This is incorrect because breastfeeding is not contraindicated in babies with TTN, unless they have severe respiratory distress or need continuous positive airway pressure (CPAP) support.
Choice D reason:
This is incorrect because TTN does not cause chronic lung disease or require oxygen therapy at home. Most babies with TTN only need supplemental oxygen for a few days until their breathing improves.
What is a sign that a newborn may be at risk for meconium aspiration syndrome?
A. Asymmetrical breathing
Asymmetrical breathing is not a sign of meconium aspiration syndrome (MAS). It is a sign of diaphragmatic hernia, a condition where the abdominal organs push into the chest cavity and interfere with lung development.
B. Born before 38 weeks gestation
Born before 38 weeks gestation is not a sign of MAS. It is a risk factor for respiratory distress syndrome (RDS), a condition where the lungs are not fully developed and lack surfactant, a substance that helps keep the air sacs open.
C. Yellow-green staining on the umbilical cord
Yellow-green staining on the umbilical cord is a sign of MAS. It indicates that the baby has passed meconium into the amniotic fluid before or during birth and may have inhaled it into the lungs. Meconium is a sticky substance that becomes the baby's first poop. It can block or irritate the airways, damage lung tissue and prevent oxygen exchange.
D. Acrocyanosis
Acrocyanosis is not a sign of MAS. It is a normal finding in newborns where the hands and feet appear bluish due to immature circulation. It usually resolves within 24 to 48 hours after birth.
Full Explanation
Choice A reason:
Asymmetrical breathing is not a sign of meconium aspiration syndrome (MAS). It is a sign of diaphragmatic hernia, a condition where the abdominal organs push into the chest cavity and interfere with lung development.
Choice B reason:
Born before 38 weeks gestation is not a sign of MAS. It is a risk factor for respiratory distress syndrome (RDS), a condition where the lungs are not fully developed and lack surfactant, a substance that helps keep the air sacs open.
Choice C reason:
Yellow-green staining on the umbilical cord is a sign of MAS. It indicates that the baby has passed meconium into the amniotic fluid before or during birth and may have inhaled it into the lungs. Meconium is a sticky substance that becomes the baby's first poop. It can block or irritate the airways, damage lung tissue and prevent oxygen exchange.
Choice D reason:
Acrocyanosis is not a sign of MAS. It is a normal finding in newborns where the hands and feet appear bluish due to immature circulation. It usually resolves within 24 to 48 hours after birth.
A nurse is reinforcing teaching with the mother of a newborn who is small for gestational age. Which of the following should the nurse include as a cause of this condition?
A. Placental insufficiency
Placental insufficiency is a condition in which the placenta does not deliver enough oxygen and nutrients to the developing baby, resulting in restricted growth and development. This is one of the most common causes of SGA babies.
B. Primipara
Primipara means a woman who is pregnant for the first time or who has given birth to one child. Primipara is not a cause of SGA, although some studies have suggested that first-time mothers may have a slightly higher risk of having a low-birth-weight baby than multiparous women.
C. Maternal obesity
Maternal obesity is a condition in which the mother has a body mass index (BMI) of 30 or higher before or during pregnancy. Maternal obesity is not a cause of SGA, but rather a risk factor for having a large-for-gestational-age (LGA) baby, which can lead to complications such as macrosomia, shoulder dystocia, and birth trauma.
D. Perinatal asphyxia
Perinatal asphyxia is a condition in which the baby does not receive enough oxygen before, during, or after birth, causing hypoxia and acidosis. Perinatal asphyxia is not a cause of SGA, but rather a possible complication of SGA, especially if the placental insufficiency is severe or prolonged. Perinatal asphyxia can damage the brain and other organs of the baby and lead to long-term neurological impairments.
Full Explanation
Choice A reason:
Placental insufficiency is a condition in which the placenta does not deliver enough oxygen and nutrients to the developing baby, resulting in restricted growth and development. This is one of the most common causes of SGA babies.
Choice B reason:
Primipara means a woman who is pregnant for the first time or who has given birth to one child. Primipara is not a cause of SGA, although some studies have suggested that first-time mothers may have a slightly higher risk of having a low-birth-weight baby than multiparous women.
Choice C reason:
Maternal obesity is a condition in which the mother has a body mass index (BMI) of 30 or higher before or during pregnancy. Maternal obesity is not a cause of SGA, but rather a risk factor for having a large-for-gestational-age (LGA) baby, which can lead to complications such as macrosomia, shoulder dystocia, and birth trauma.
Choice D reason:
Perinatal asphyxia is a condition in which the baby does not receive enough oxygen before, during, or after birth, causing hypoxia and acidosis. Perinatal asphyxia is not a cause of SGA, but rather a possible complication of SGA, especially if the placental insufficiency is severe or prolonged. Perinatal asphyxia can damage the brain and other organs of the baby and lead to long-term neurological impairments.