Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse on an antepartum unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first?
A. A client who is at 34 weeks of gestation and is experiencing epigastric pain and headache.
The nurse should assess this client first as they are at 34 weeks of gestation and experiencing epigastric pain and headache. These symptoms could be indicative of preeclampsia, a serious pregnancy complication characterized by high blood pressure and organ damage. Preeclampsia requires immediate assessment and intervention to prevent further complications.
B. A client who is at 12 weeks of gestation and is experiencing nausea and vomiting.
Nausea and vomiting are common symptoms during the first trimester of pregnancy, and at 12 weeks of gestation, it is less likely to be a critical issue compared to potential preeclampsia.
C. A client who is at 38 weeks of gestation and is experiencing painful urination.
Painful urination may indicate a urinary tract infection, which can be important to assess and treat, but it is not as urgent as potential signs of preeclampsia in a client at 34 weeks of gestation.
D. A client who is at 39 weeks of gestation and is experiencing cramping and spotting.
Cramping and spotting can be normal signs of impending labor, especially at 39 weeks of gestation. While it's important to assess this client, it is not the priority over potential preeclampsia in a client at 34 weeks of gestation with symptoms of epigastric pain and headache.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Maternal Newborn 2019 NGN Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
The nurse should assess this client first as they are at 34 weeks of gestation and experiencing epigastric pain and headache. These symptoms could be indicative of preeclampsia, a serious pregnancy complication characterized by high blood pressure and organ damage. Preeclampsia requires immediate assessment and intervention to prevent further complications.
Choice B rationale:
Nausea and vomiting are common symptoms during the first trimester of pregnancy, and at 12 weeks of gestation, it is less likely to be a critical issue compared to potential preeclampsia.
Choice C rationale:
Painful urination may indicate a urinary tract infection, which can be important to assess and treat, but it is not as urgent as potential signs of preeclampsia in a client at 34 weeks of gestation.
Choice D rationale:
Cramping and spotting can be normal signs of impending labor, especially at 39 weeks of gestation. While it's important to assess this client, it is not the priority over potential preeclampsia in a client at 34 weeks of gestation with symptoms of epigastric pain and headache.
Similar Questions
A nurse is providing prenatal teaching to a client who practices a vegan diet and is trying to increase her intake of vitamin B12. Which of the following foods should the nurse recommend?
A. Fresh citrus fruits.
Fresh citrus fruits are not a good source of vitamin B12. They are rich in vitamin C but do not contain vitamin B12.
B. Brown rice.
Brown rice is not a good source of vitamin B12. While it is a nutritious grain, it does not contain vitamin B12.
C. Raw carrots.
Raw carrots are not a good source of vitamin B12. Carrots provide essential nutrients but do not contain vitamin B12.
D. Fortified soy milk.
Fortified soy milk is the correct choice as it is a suitable option for someone on a vegan diet looking to increase their vitamin B12 intake. Many brands of soy milk are fortified with vitamin B12, making it a reliable source for vegans. Vitamin B12 is essential for nerve function and red blood cell production, making it especially important during pregnancy.
Full Explanation
Choice A rationale:
Fresh citrus fruits are not a good source of vitamin B12. They are rich in vitamin C but do not contain vitamin B12.
Choice B rationale:
Brown rice is not a good source of vitamin B12. While it is a nutritious grain, it does not contain vitamin B12.
Choice C rationale:
Raw carrots are not a good source of vitamin B12. Carrots provide essential nutrients but do not contain vitamin B12.
Choice D rationale:
Fortified soy milk is the correct choice as it is a suitable option for someone on a vegan diet looking to increase their vitamin B12 intake. Many brands of soy milk are fortified with vitamin B12, making it a reliable source for vegans. Vitamin B12 is essential for nerve function and red blood cell production, making it especially important during pregnancy.
A nurse is caring for a client who has had a pudendal nerve block. The nurse should monitor which of the following findings has an adverse effect.
A. Fetal bradycardia.
Fetal bradycardia is not a common adverse effect of a pudendal nerve block. This block primarily affects the mother’s pelvic region and does not typically impact fetal heart rate.
B. Decreased ability to bear down.
Decreased ability to bear down is correct because the pudendal nerve block can numb the perineal area, reducing the mother’s ability to feel contractions and effectively bear down during labor.
C. Maternal hypertension.
Maternal hypertension is not associated with pudendal nerve blocks. This block is localized and does not generally affect systemic blood pressure.
D. Uterine hyperstimulation.
Uterine hyperstimulation is not a known adverse effect of pudendal nerve blocks. This condition is more commonly associated with the use of labor-inducing drugs like oxytocin.
Full Explanation
The correct answer is choice B. Decreased ability to bear down.
Choice A rationale:
Fetal bradycardia is not a common adverse effect of a pudendal nerve block. This block primarily affects the mother’s pelvic region and does not typically impact fetal heart rate.
Choice B rationale:
Decreased ability to bear down is correct because the pudendal nerve block can numb the perineal area, reducing the mother’s ability to feel contractions and effectively bear down during labor.
Choice C rationale:
Maternal hypertension is not associated with pudendal nerve blocks. This block is localized and does not generally affect systemic blood pressure.
Choice D rationale:
Uterine hyperstimulation is not a known adverse effect of pudendal nerve blocks. This condition is more commonly associated with the use of labor-inducing drugs like oxytocin.
A nurse is providing teaching to a client who reports that her baby has yellow discharge forming at the circumcision site. Which of the following is an appropriate response by the nurse?
A. "I will need to obtain a sample of the discharge for laboratory testing.".
The nurse does not need to obtain a sample of the discharge for laboratory testing at this point. Yellow discharge after circumcision is common and generally not a cause for immediate concern. Laboratory testing is not necessary for routine circumcision care.
B. "Apply povidone-iodine solution twice daily to the circumcision site.".
Applying povidone-iodine solution twice daily to the circumcision site is not recommended in this situation. Povidone-iodine may cause irritation and delay the natural healing process. Generally, no specific cleaning solution is required for circumcision care unless otherwise indicated by a healthcare provider.
C. "Wipe the discharge away gently with a washcloth and warm water for the next 48 hours.".
Wiping the discharge away gently with a washcloth and warm water for the next 48 hours is not the most appropriate action. The circumcision site should be kept clean and dry, but actively wiping away the discharge may cause irritation and disrupt the natural healing process.
D. "The discharge is common during the first 24 to 72 hours following a circumcision.".
The discharge is common during the first 24 to 72 hours following a circumcision
Full Explanation
Choice A rationale:
The nurse does not need to obtain a sample of the discharge for laboratory testing at this point. Yellow discharge after circumcision is common and generally not a cause for immediate concern. Laboratory testing is not necessary for routine circumcision care.
Choice B rationale:
Applying povidone-iodine solution twice daily to the circumcision site is not recommended in this situation. Povidone-iodine may cause irritation and delay the natural healing process.
Generally, no specific cleaning solution is required for circumcision care unless otherwise indicated by a healthcare provider.
Choice C rationale:
Wiping the discharge away gently with a washcloth and warm water for the next 48 hours is not the most appropriate action. The circumcision site should be kept clean and dry, but actively wiping away the discharge may cause irritation and disrupt the natural healing process.