Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse on the labor and delivery unit is planning care for a client who has human immunodeficiency virus (HIV). Which of the following is an appropriate action for the nurse to take following the birth of the newborn?
A. Initiate contact precautions for the newborn.
While contact precautions may be necessary for certain infections, they are not specifically required for an HIV-positive mother’s newborn if the infant is not infected. The newborn’s HIV status should be confirmed through testing.
B. Administer IV antibiotics to the newborn.
IV antibiotics are not routinely administered to newborns of HIV-positive mothers unless there is a specific indication for infection prevention or treatment.
C. Cleanse the newborn immediately after delivery.
It is crucial to clean the newborn promptly after delivery to reduce the risk of HIV transmission, as HIV can be present in blood and other bodily fluids. Proper cleansing helps minimize the risk of exposure.
D. Encourage the mother to breastfeed her newborn.
Breastfeeding is contraindicated for mothers with HIV because HIV can be transmitted through breast milk. Instead, formula feeding is recommended to prevent transmission.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Maternal Newborn 2019 with NGN Proctored Exam. Take the full exam now
Full Explanation
A. While contact precautions may be necessary for certain infections, they are not specifically required for an HIV-positive mother’s newborn if the infant is not infected. The newborn’s HIV status should be confirmed through testing.
B. IV antibiotics are not routinely administered to newborns of HIV-positive mothers unless there is a specific indication for infection prevention or treatment.
C. It is crucial to clean the newborn promptly after delivery to reduce the risk of HIV transmission, as HIV can be present in blood and other bodily fluids. Proper cleansing helps minimize the risk of exposure.
D. Breastfeeding is contraindicated for mothers with HIV because HIV can be transmitted through breast milk. Instead, formula feeding is recommended to prevent transmission.
Similar Questions
A nurse is teaching a newly hired nurse about Apgar scoring. Which of the following statements by the newly hired nurse indicates an understanding of the teaching?
A. "The nurse should determine the Apgar score at 2 and 7 minutes after birth."
B. "The nurse should identify that the newborn is in severe distress with an Apgar score of 8."
C. "The nurse should wait for the first Apgar score before initiating resuscitation efforts."
D. "The nurse should measure the newborn's muscle tone when assigning an Apgar score."
Component 0 Points 1 Point 2 Points Heart Rate Absent <100 bpm >100 bpm Respiratory Effort Absent Slow, irregular Good, crying Muscle Tone Flaccid Some flexion Active motion Reflex Irritability No response Grimace Vigorous cry Color Blue, pale Body pink, extremities blue Completely pink The score for each component is summed up to a maximum score of 10, with 10 indicating the healthiest newborn. The NRP guidelines emphasize that resuscitation efforts should be initiated immediately after delivery, regardless of the Apgar score, thus choice C is wrong.
Full Explanation
The correct answer is choice D. "The nurse should measure the newborn's muscle tone when assigning an Apgar score." components of the Apgar score:
|
Component |
0 Points |
1 Point |
2 Points |
|
Heart Rate |
Absent |
<100 bpm |
>100 bpm |
|
Respiratory Effort |
Absent |
Slow, irregular |
Good, crying |
|
Muscle Tone |
Flaccid |
Some flexion |
Active motion |
|
Reflex Irritability |
No response |
Grimace |
Vigorous cry |
|
Color |
Blue, pale |
Body pink, extremities blue |
Completely pink |
The score for each component is summed up to a maximum score of 10, with 10 indicating the healthiest newborn. The NRP guidelines emphasize that resuscitation efforts should be initiated immediately after delivery, regardless of the Apgar score, thus choice C is wrong.
A nurse is caring for a client who is at 30 weeks of gestation and is receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations as an adverse reaction to the medication.
A. Hyperglycemia
B. Hypertension
C. Respiratory rate 16/min
D. Urine output 20 mL/hr
A urine output of 20 mL/hr is a manifestation of an adverse reaction to magnesium sulfate. Magnesium sulfate is a medication used to treat preeclampsia, a potentially life-threatening condition that can occur during pregnancy. Adverse reactions to magnesium sulfate include hypotension, respiratory depression, and decreased urine output. The nurse should monitor the client's vital signs and urine output closely while the client is receiving magnesium sulfate. Normal urine output in a healthy individual should be between 0.5-1.5 mL/kg/hour, and patients should generally be urinating at least every 6 hours.
Full Explanation
The correct answer is choice D. Urine output of 20 mL/hr is a manifestation of an adverse reaction to magnesium sulfate. Magnesium sulfate is a medication used to treat preeclampsia, a potentially life-threatening condition that can occur during pregnancy. Adverse reactions to magnesium sulfate include hypotension, respiratory depression, and decreased urine output. The nurse should monitor the client's vital signs and urine output closely while the client is receiving magnesium sulfate. Normal urine output in a healthy individual should be between 0.5-1.5 mL/kg/hour, and patients should generally be urinating at least every 6 hours.
A nurse is caring for a client who is in active labor and reports sudden, severe lower abdominal pain. The nurse observes a drop in the client's blood pressure and notes cool skin and pallor. The fetal heart rate tracing shows prolonged bradycardia. Which of the following complications should the nurse suspect?
A. Amniotic fluid embolism
B. Umbilical cord prolapse
C. Uterine rupture
Uterine rupture. The sudden, severe lower abdominal pain, drop in blood pressure, and signs of shock such as cool skin and pallor all point to a potential intra-abdominal hemorrhage most likely due to Uterine rupture. Additionally, the prolonged bradycardia on the fetal heart rate tracing indicates that the baby may be experiencing fetal distress due to a compromised blood supply. Amniotic fluid embolism triggers an allergic reaction, causing a sudden onset of respiratory distress, hypotension, and cardiac arrest. Option D, placenta previa, occurs when the placenta implants in the lower uterine segment, partially or completely covering the cervical os. This can lead to painless vaginal bleeding but typically does not present with sudden, severe abdominal pain or signs of shock.
D. Placenta previa
which suggests that the nurse should assess the newborn's latch while breastfeeding. Sore nipples are a common concern among breastfeeding mothers, and the most common cause is an improper latch. The nurse should ensure that the baby is latching on correctly and not causing trauma to the mother's nipples. A proper latch involves the baby taking in a good portion of the areola and not just the nipple. Assessing the newborn's latch can help identify any issues with the baby's mouth or tongue that may be causing difficulty latching on. If the baby is not latching correctly, the nurse can provide education and support to help the mother correct the issue. Offering supplemental formula between feedings (choice A) is not recommended as it can decrease the frequency of breastfeeding and reduce the stimulation for milk production, leading to decreased milk supply. Instructing the client to wait 4 hours between daytime feedings (choice C) is not recommended as it can decrease milk production and lead to inadequate nutrition for the newborn.
Full Explanation
Uterine rupture. The sudden, severe lower abdominal pain, drop in blood pressure, and signs of shock such as cool skin and pallor all point to a potential intra-abdominal hemorrhage most likely due to Uterine rupture. Additionally, the prolonged bradycardia on the fetal heart rate tracing indicates that the baby may be experiencing fetal distress due to a compromised blood supply. Amniotic fluid embolism triggers an allergic reaction, causing a sudden onset of respiratory distress, hypotension, and cardiac arrest. Option D, placenta previa, occurs when the placenta implants in the lower uterine segment, partially or completely covering the cervical os. This can lead to painless vaginal bleeding but typically does not present with sudden, severe abdominal pain or signs of shock.
