Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reviewing the laboratory results of a newborn.
Which of the following findings should the nurse report to the provider?
A. Platelets 100,000/mm
Thrombocytopenia is defined as a platelet count of less than 150,000/microL. Severe neonatal thrombocytopenia (platelet count <50,000/microL) can be associated with bleeding and potentially significant morbidity. As a result, it is important to identify at-risk neonates and report low platelet counts to the provider.
B. Hematocrit 48%
Choice B is incorrect because a hematocrit of 48% is within the normal range for a newborn.
C. Blood glucose 58 mg/dl.
Choice C is incorrect because a blood glucose level of 58 mg/dl is within the normal range for a newborn.
D. Hemoglobin 16 g/dL.
Choice D is incorrect because a hemoglobin level of 16 g/dL is within the normal range for a newborn.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Maternal Newborn 2019 with NGN Proctored Exam. Take the full exam now
Full Explanation
Thrombocytopenia is defined as a platelet count of less than 150,000/microL1.
Severe neonatal thrombocytopenia (platelet count <50,000/microL) can be associated with bleeding and potentially significant morbidity.
As a result, it is important to identify at-risk neonates and report low platelet counts to the provider.
Choice B is incorrect because a hematocrit of 48% is within the normal range for a newborn.
Choice C is incorrect because a blood glucose level of 58 mg/dl is within the normal range for a newborn.
Choice D is incorrect because a hemoglobin level of 16 g/dL is within the normal range for a newborn.
Similar Questions
A nurse is caring for a client who is in the latent phase of the first stage of labor and is in pain.
Which of the following nursing interventions are appropriate to reduce pain? (Select all that apply.)
A. Perform Leopold maneuvers.
Choice A is incorrect because performing Leopold maneuvers is a technique used to assess fetal position and presentation and is not a pain management technique.
B. Apply counterpressure to the sacral area
Applying counterpressure to the sacral area can help alleviate back pain during labor.
C. Ambulate the client in the hallway
Ambulating the client in the hallway can help with pain management and facilitate labor progress.
D. Administer 70-90% nitrous oxide mixed with oxygen
Administering nitrous oxide mixed with oxygen can provide pain relief during labor.
Full Explanation
Applying counterpressure to the sacral area can help alleviate back pain during labor.
Ambulating the client in the hallway can help with pain management and facilitate labor progress.
Administering nitrous oxide mixed with oxygen can provide pain relief during labor.
Having the client sit upright can help with pain management and facilitate labor progress.
Choice A is incorrect because performing Leopold maneuvers is a technique used to assess fetal position and presentation and is not a pain management technique.
A nurse is assessing a client who is in preterm labor and has a new prescription for terbutaline 0.25 mg subcutaneous.
For which of the following findings should the nurse withhold the medication and report to the provider?
A. BP 88/58 mm Hg
Terbutaline is a medication that can cause serious side effects such as ante (low blood pressure). A blood pressure reading of 88/58 mm Hg is considered low and could be a sign of hypotension. The nurse should withhold the medication and report this finding to the provider.
B. Urinary output 40 mL/hr
Choice B is not an answer because a urinary output of 40 mL/hr is within the normal range.
C. FHR 120/min.
Choice D is not an answer because a fetal heart rate (FHR) of 120/min is within the normal range.
D. Fasting blood glucose 75 mg/dL
Choice C is not an answer because a fasting blood glucose level of 75 mg/dL is within the normal range.
Full Explanation
Terbutaline is a medication that can cause serious side effects such as ante (low blood pressure).
A blood pressure reading of 88/58 mm Hg is considered low and could be a sign
of hypotension.
The nurse should withhold the medication and report this finding to the provider.
Choice B is not an answer because a urinary output of 40 mL/hr is within the
normal range.
Choice C is not an answer because a fetal heart rate (FHR) of 120/min is within the normal range.
Choice D is not an answer because a fasting blood glucose level of 75 mg/dL is
within the normal range.
A client who is at 16 weeks of gestation asks a nurse how to prepare her toddler to have a younger sibling.
Which of the following statements should the nurse make?
A. "You should place your toddler in time-out if she exhibits regressive behavior after the baby is born."
B. "You should move your toddler out of her crib 2 weeks prior to your due date."
C. You should hold your newborn in your arms when you introduce him to your toddler."
D. "You should tell your toddler that the baby will need all your attention, but they will still be important."
A. "You should place your toddler in time-out if she exhibits regressive behavior
Choice A: This approach is not suitable for dealing with regressive behaviors in toddlers. Regressive behavior, such as wanting to sleep in the crib or revert to bottle-feeding, is a normal response to the stress of a new sibling. Instead of punishment, parents should provide reassurance, comfort, and understanding. Time-outs may exacerbate feelings of insecurity rather than alleviate them.
B. "You should move your toddler out of her crib 2 weeks prior to your due date."
Choice B: While transitioning a toddler out of the crib can be a part of preparation, it should not be rushed. Doing so too early may create unnecessary stress for the toddler. The best time to make significant changes (like transitioning to a bed) is when the toddler is ready, and it should be done with care and gradual preparation, not too close to the arrival of the baby.
C. "You should hold your newborn in your arms when you introduce him to your toddler.”
Choice C: This is the most appropriate advice. It’s important to allow the toddler to feel involved and included in the process, but holding the newborn during the introduction helps minimize feelings of jealousy and ensures the toddler doesn't feel displaced. Holding the baby allows the toddler to approach the situation more calmly, and it can also help foster a sense of love and comfort for both the toddler and the newborn.
D. "You should tell your toddler that the baby will need all your attention, but they will still be important."
“While it’s important to reassure the toddler that they are still loved and important, this statement might unintentionally increase anxiety or make the toddler feel less valued. Instead, the nurse should encourage a positive approach, where the toddler can learn how to be a helper and feel involved in the care of the newborn. It’s essential to focus on inclusivity rather than highlighting potential feelings of neglect.
Full Explanation
Correct answer: C- "You should hold your newborn in your arms when you introduce him to your toddler.”
Choice A is not an answer because this approach is not suitable for dealing with regressive behaviors in toddlers. Regressive behavior, such as wanting to sleep in the crib or revert to bottle-feeding, is a normal response to the stress of a new sibling. Instead of punishment, parents should provide reassurance, comfort, and understanding. Time-outs may exacerbate feelings of insecurity rather than alleviate them.
Choice B is not an answer because While transitioning a toddler out of the crib can be a part of preparation, it should not be rushed. Doing so too early may create unnecessary stress for the toddler. The best time to make significant changes (like transitioning to a bed) is when the toddler is ready, and it should be done with care and gradual preparation, not too close to the arrival of the baby.
Choice C is the most appropriate answer because It’s important to allow the toddler to feel involved and included in the process, but holding the newborn during the introduction helps minimize feelings of jealousy and ensures the toddler doesn't feel displaced. Holding the baby allows the toddler to approach the situation more calmly, and it can also help foster a sense of love and comfort for both the toddler and the newborn.
Choice D: While it’s important to reassure the toddler that they are still loved and important, this statement might unintentionally increase anxiety or make the toddler feel less valued. Instead, the nurse should encourage a positive approach, where the toddler can learn how to be a helper and feel involved in the care of the newborn. It’s essential to focus on inclusivity rather than highlighting potential feelings of neglect.