Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse on a postpartum unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?
A. A client who gave birth 1 day ago and needs Rh(D) immune globulin.
A client who gave birth 1 day ago and needs Rh(D) immune globulin should be seen soon but not necessarily first. Rh(D) immune globulin is administered to Rh-negative mothers with Rh- positive infants to prevent isoimmunization in future pregnancies.
B. A client who gave birth 3 days ago and reports breast fullness.
A client who gave birth 3 days ago and reports breast fullness is likely experiencing normal postpartum breast engorgement. This client can be attended to after the client with more urgent symptoms.
C. A client who gave birth 12 hr ago and reports an increase in urinary output.
A client who gave birth 12 hours ago and reports an increase in urinary output might have diuresis, which is a common postpartum physiological change. Although this requires assessment, it is not as urgent as the client in choice D.
D. A client who gave birth 8 hr ago and is saturating a perineal pad every hour.
The nurse should see the client who gave birth 8 hours ago and is saturating a perineal pad every hour first because excessive postpartum bleeding could indicate hemorrhage, a potentially life-threatening complication. Immediate assessment and intervention are crucial in this situation.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Maternal Newborn Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
A client who gave birth 1 day ago and needs Rh(D) immune globulin should be seen soon but not necessarily first. Rh(D) immune globulin is administered to Rh-negative mothers with Rh- positive infants to prevent isoimmunization in future pregnancies.
Choice B rationale:
A client who gave birth 3 days ago and reports breast fullness is likely experiencing normal postpartum breast engorgement. This client can be attended to after the client with more urgent symptoms.
Choice C rationale:
A client who gave birth 12 hours ago and reports an increase in urinary output might have diuresis, which is a common postpartum physiological change. Although this requires assessment, it is not as urgent as the client in choice D.
Choice D rationale:
The nurse should see the client who gave birth 8 hours ago and is saturating a perineal pad every hour first because excessive postpartum bleeding could indicate hemorrhage, a potentially life-threatening complication. Immediate assessment and intervention are crucial in this situation.
Similar Questions
A nurse is conducting an infertility assessment for a newly admitted client. Which of the following factors should the nurse identify as affecting the client's fertility?
A. Premature ovarian failure.
Premature ovarian failure affects the ovaries and leads to early menopause, resulting in the loss of the woman's reproductive ability. This condition can cause infertility due to the depletion or dysfunction of eggs in the ovaries, hindering conception.
B. Renal calculi.
Renal calculi (kidney stones) do not directly impact fertility. It is a condition unrelated to the reproductive system.
C. Dysmenorrhea.
Dysmenorrhea refers to painful menstruation and, while it can be uncomfortable, it does not necessarily affect fertility.
D. Recurrent urinary tract infections.
Recurrent urinary tract infections may be a concern for overall health but do not necessarily directly impact fertility unless there are severe complications. They are unrelated to infertility assessment.
Full Explanation
Choice A rationale:
Premature ovarian failure affects the ovaries and leads to early menopause, resulting in the loss of the woman's reproductive ability. This condition can cause infertility due to the depletion or dysfunction of eggs in the ovaries, hindering conception.
Choice B rationale:
Renal calculi (kidney stones) do not directly impact fertility. It is a condition unrelated to the reproductive system.
Choice C rationale:
Dysmenorrhea refers to painful menstruation and, while it can be uncomfortable, it does not necessarily affect fertility.
Choice D rationale:
Recurrent urinary tract infections may be a concern for overall health but do not necessarily directly impact fertility unless there are severe complications. They are unrelated to infertility assessment.
A nurse is caring for a client who is pregnant for the fourth time. The client delivered two full- term newborns and had one spontaneous abortion at 10 weeks of gestation. The nurse should document the client's obstetrical history as which of the following?
A. Gravida 3, Para 2.
Gravida refers to the number of times a woman has been pregnant, and Para indicates the number of pregnancies that have reached viability (at least 20 weeks) Since the client has been pregnant for the fourth time and delivered two full-term newborns (reached viability), she is gravida 4, and since she had one spontaneous abortion (miscarriage) at 10 weeks of gestation, she is para 2 (two pregnancies reached viability)
B. Gravida 3, Para 3.
This choice would be incorrect because it indicates that the client has had three pregnancies reaching viability, but she has only had two full-term newborns and one miscarriage.
C. Gravida 4, Para 2.
This is the correct choice, as explained above.
D. Gravida 4, Para 3.
This choice would be incorrect because it indicates that the client has had four pregnancies reaching viability, but she has only had two full-term newborns and one miscarriage.
Full Explanation
Choice A rationale:
Gravida refers to the number of times a woman has been pregnant, and Para indicates the number of pregnancies that have reached viability (at least 20 weeks) Since the client has
been pregnant for the fourth time and delivered two full-term newborns (reached viability), she is gravida 4, and since she had one spontaneous abortion (miscarriage) at 10 weeks of gestation, she is para 2 (two pregnancies reached viability)
Choice B rationale:
This choice would be incorrect because it indicates that the client has had three pregnancies reaching viability, but she has only had two full-term newborns and one miscarriage.
Choice C rationale:
This is the correct choice, as explained above. Choice D rationale:
This choice would be incorrect because it indicates that the client has had four pregnancies reaching viability, but she has only had two full-term newborns and one miscarriage.
A nurse is providing teaching to a client who is at 32 weeks of gestation and is experiencing stress incontinence. Which of the following information should the nurse include in the teaching? (Select all that apply.)
A. Decrease dietary fiber.
This would be incorrect advice. Increasing dietary fiber is commonly recommended during pregnancy to prevent constipation, but it does not address stress incontinence.
B. Practice Kegel exercises.
This is a correct choice. Kegel exercises are beneficial during pregnancy to strengthen the pelvic floor muscles, which can help manage stress incontinence.
C. Restrict daily fluid intake.
This would be incorrect advice. Restricting daily fluid intake during pregnancy is generally not recommended as it can lead to dehydration and is unlikely to improve stress incontinence.
D. Reduce caffeine intake.
This is another correct choice. Caffeine is a bladder irritant and can worsen stress incontinence, so reducing caffeine intake can be helpful.
E. Avoid daily exercise.
This would be incorrect advice. Regular exercise during pregnancy is generally encouraged unless there are specific medical reasons to avoid it. Avoiding daily exercise is not the appropriate approach to manage stress incontinence.
Full Explanation
Choice A rationale:
This would be incorrect advice. Increasing dietary fiber is commonly recommended during pregnancy to prevent constipation, but it does not address stress incontinence.
Choice B rationale:
This is a correct choice. Kegel exercises are beneficial during pregnancy to strengthen the pelvic floor muscles, which can help manage stress incontinence.
Choice C rationale:
This would be incorrect advice. Restricting daily fluid intake during pregnancy is generally not recommended as it can lead to dehydration and is unlikely to improve stress incontinence.
Choice D rationale:
This is another correct choice. Caffeine is a bladder irritant and can worsen stress incontinence, so reducing caffeine intake can be helpful.
Choice E rationale:
This would be incorrect advice. Regular exercise during pregnancy is generally encouraged unless there are specific medical reasons to avoid it. Avoiding daily exercise is not the appropriate approach to manage stress incontinence.