Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is updating the plan of care for a newborn who is undergoing phototherapy. Which of the following actions should the nurse include in the plan?
A. Monitor the newborn's blood glucose level hourly.
Monitoring the newborn's blood glucose level hourly is not necessary for a newborn undergoing phototherapy. Phototherapy does not affect blood glucose levels, and hourly monitoring would be too invasive and stressful for the newborn.
B. Apply lotion to the newborn's skin twice per day.
Applying lotion to the newborn's skin twice per day is not recommended for a newborn undergoing phototherapy. Lotion can interfere with the effectiveness of the phototherapy and increase the risk of skin irritation or infection.
C. Maintain the newborn in a prone position
Maintaining the newborn in a prone position is not advisable for a newborn undergoing phototherapy. The newborn should be positioned on alternate sides to expose as much skin surface as possible to the light source.
D. Encourage the newborn to breastfeed every 2 hr.
Encouraging the newborn to breastfeed every 2 hr is an appropriate action for a newborn undergoing phototherapy. Frequent feeding helps to promote hydration and the elimination of bilirubin from the body.
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:
Monitoring the newborn's blood glucose level hourly is not necessary for a newborn undergoing phototherapy. Phototherapy does not affect blood glucose levels, and hourly monitoring would be too invasive and stressful for the newborn. •
Choice B reason:
Applying lotion to the newborn's skin twice per day is not recommended for a newborn undergoing phototherapy. Lotion can interfere with the effectiveness of the phototherapy and increase the risk of skin irritation or infection. •
Choice C reason:
Maintaining the newborn in a prone position is not advisable for a newborn undergoing phototherapy. The newborn should be positioned on alternate sides to expose as much skin surface as possible to the light source. •
Choice D reason:
Encouraging the newborn to breastfeed every 2 hr is an appropriate action for a newborn undergoing phototherapy. Frequent feeding helps to promote hydration and the elimination of bilirubin from the body.
Similar Questions
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.
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.
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.