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NurseDive Free Nursing Practice Question
A nurse is reinforcing teaching about home safety precautions with the parents of a 3-month- old infant.
Which of the following instructions should the nurse include in the teaching?
A. Place no more than one small pillow in the crib.
The American Academy of Pediatrics (AAP) recommends that infants should sleep on a firm and flat surface without any pillows, blankets, or soft bedding. These items can pose a suffocation risk. So, the nurse should advise against using any pillows in the crib.
B. Remove bibs when the infant is going to sleep.
This is a good recommendation. Bibs can be a choking hazard during sleep. Removing them ensures the baby’s safety and reduces the risk of accidental suffocation
C. Make sure the crib mattress is soft.
Is not recommended. The crib mattress should be firm to provide a safe sleeping surface for the infant. Soft mattresses can increase the risk of suffocation.
D. Start using a highchair for feedings.
Is not typically necessary or developmentally appropriate. At this age, infants are typically fed while being held in a caregiver's arms or in a reclined position, such as in a baby bouncer or supported seat.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Comprehensive Predictor 2023 - Proctored Exam 1. Take the full exam now
Full Explanation
Correct answer: B
A. Place no more than one small pillow in the crib
The American Academy of Pediatrics (AAP) recommends that infants should sleep on a firm and flat surface without any pillows, blankets, or soft bedding. These items can pose a suffocation risk. So, the nurse should advise against using any pillows in the crib.
B. This is a good recommendation. Bibs can be a choking hazard during sleep. Removing them ensures the baby’s safety and reduces the risk of accidental suffocation
C. Making sure the crib mattress is soft in (option C) is not recommended. The crib mattress should be firm to provide a safe sleeping surface for the infant. Soft mattresses can increase the risk of suffocation.
D. Starting to use a highchair for feedings at 3 months old in (option D) is not typically necessary or developmentally appropriate. At this age, infants are typically fed while being held in a caregiver's arms or in a reclined position, such as in a baby bouncer or supported seat.
Similar Questions
A nurse is collecting data from a client who has heart failure. The nurse notes the client has crackles in the bases of the lungs, shortness of breath, and a respiratory rate of 24/min.
Which of the following actions should the nurse take?
A. Instruct the client to cough every 4 hr.
Is not the priority action in this situation. Coughing may not effectively address the underlying cause of pulmonary congestion and may not provide immediate relief for the client.
B. Encourage the client to ambulate to loosen secretions.
Is not the priority action in this situation. While ambulation can be beneficial for overall health, the client's symptoms of pulmonary congestion require immediate attention to improve respiratory status.
C. Increase the client's intake of oral fluids.
Is not the priority action in this situation. While maintaining adequate hydration is important, excessive fluid intake can worsen the symptoms of heart failure and contribute to further fluid accumulation in the lungs.
D. Maintain the client in high-Fowler's position.
Crackles in the bases of the lungs, shortness of breath, and an increased respiratory rate are signs of pulmonary congestion, which is commonly seen in heart failure. Maintaining the client in a high-Fowler's position, with the head of the bed elevated to a 45-60-degree angle, helps reduce venous return to the heart, decreases fluid accumulation in the lungs, and improves breathing comfort for the client.
Full Explanation
Explanation
D. Maintain the client in high-Flower’s position
Crackles in the bases of the lungs, shortness of breath, and an increased respiratory rate are signs of pulmonary congestion, which is commonly seen in heart failure. Maintaining the client in a high-Fowler's position, with the head of the bed elevated to a 45-60-degree angle, helps reduce venous return to the heart, decreases fluid accumulation in the lungs, and improves breathing comfort for the client.
The other options are not appropriate actions for the client's condition:
Instructing the client to cough every 4 hours in (option A) is not the priority action in this situation. Coughing may not effectively address the underlying cause of pulmonary congestion and may not provide immediate relief for the client.
Encouraging the client to ambulate to loosen secretions in (option B) is not the priority action in this situation. While ambulation can be beneficial for overall health, the client's symptoms of pulmonary congestion require immediate attention to improve respiratory status.
Increasing the client's intake of oral fluids in (option C) is not the priority action in this situation. While maintaining adequate hydration is important, excessive fluid intake can worsen the symptoms of heart failure and contribute to further fluid accumulation in the lungs.
Therefore, the nurse should maintain the client in high-Fowler's position (option D) to promote optimal lung function and improve breathing comfort. It is important to promptly notify the healthcare provider of the client's condition for further assessment and intervention.
A nurse is assisting with the care of a client who is in the latent stage of labor and has pelvic pain with contractions.
Which of the following actions should the nurse take?
A. Apply fundal pressure during contractions.
Is not necessary during the latent stage of labour. Fundal pressure is typically used in the active stage of labour to assist with the descent and positioning of the baby's head.
B. Instruct the client to change positions frequently.
Encouraging the client to move around, walk, change positions during labour can help relieve discomfort, promote optimal fetal positioning positions, or use a birthing ball can help alleviate pelvic pain and potentially facilitate the progress of labour.
C. Tell the client to push during contractions.
Is not appropriate during the latent stage of labour. Pushing is typically reserved for the second stage of labour when the cervix is fully dilated.
D. Encourage the client to soak in a hot bath.
Is not recommended during labour, particularly in the hospital setting. Immersion in hot water (e.g., a hot bath) can increase the risk of infection and is generally not recommended until after the birth of the baby
Full Explanation
Explanation
B. Instruct the client to change positions frequently
Encouraging the client to move around, walk, change positions during labour can help relieve discomfort, promote optimal fetal positioning positions, or use a birthing ball can help alleviate pelvic pain and potentially facilitate the progress of labour.
Applying fundal pressure during contractions in (option A) is not necessary during the latent stage of labour. Fundal pressure is typically used in the active stage of labour to assist with the descent and positioning of the baby's head.
Telling the client to push during contractions in (option C) is not appropriate during the latent stage of labour. Pushing is typically reserved for the second stage of labour when the cervix is fully dilated.
Encouraging the client to soak in a hot bath in (option D) is not recommended during labour, particularly in the hospital setting. Immersion in hot water (e.g., a hot bath) can increase the risk of infection and is generally not recommended until after the birth of the baby
A nurse is assisting in the care of a client who is at 34 weeks of gestation and is experiencing lower back pain. Which of the following recommendations should the nurse make?
A. Sit in a hot tub for 30 min every evening
Sit in a hot tub for 30 min every evening: Hot tubs and hot baths are not recommended during pregnancy as they can raise the body temperature too high, which can be harmful to the developing fetus.
B. Raise chairs to keep knees lower than hips
Raise chairs to keep knees lower than hips: This recommendation is more appropriate for promoting good posture and reducing strain on the back, but it may not specifically address lower back pain.
C. Use the arms to pick up heavy items
Use the arms to pick up heavy items: It is important to avoid heavy lifting during pregnancy as it can strain the back and increase the risk of injury. It is recommended to use proper lifting techniques, such as bending the knees and using the leg muscles rather than the back muscles, to lift objects.
D. Perform pelvic rocking exercises several times per day
Pelvic rocking exercises can help relieve lower back pain during pregnancy. The client can perform this exercise by getting on their hands and knees, keeping their back straight, and gently rocking their pelvis back and forth. This helps to stretch and strengthen the muscles in the lower back and pelvis.
Full Explanation
Pelvic rocking exercises can help relieve lower back pain during pregnancy. The client can perform this exercise by getting on their hands and knees, keeping their back straight, and gently rocking their pelvis back and forth. This helps to stretch and strengthen the muscles in the lower back and pelvis.
Sit in a hot tub for 30 min every evening: Hot tubs and hot baths are not recommended during pregnancy as they can raise the body temperature too high, which can be harmful to the developing fetus.
Raise chairs to keep knees lower than hips: This recommendation is more appropriate for promoting good posture and reducing strain on the back, but it may not specifically address lower back pain.
Use the arms to pick up heavy items: It is important to avoid heavy lifting during pregnancy as it can strain the back and increase the risk of injury. It is recommended to use proper lifting techniques, such as bending the knees and using the leg muscles rather than the back muscles, to lift objects.