Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A postpartum woman telephones about her 4-day-old infant. She is not scheduled for a weight check until the infant is 10 days old, and she is worried about whether breastfeeding is going well. Effective breastfeeding is indicated by the newborn who:
A. has at least six to eight wet diapers per day.
is the correct answer because the number of wet diapers a newborn has per day is a reliable indicator of effective breastfeeding. When a baby is breastfeeding well and getting enough milk, they will have an adequate number of wet diapers, typically at least six to eight per day. The frequent wet diapers indicate that the baby is adequately hydrated, and their body is eliminating waste products as expected.
B. has at least one breast milk stool every 24 hours.
having at least one breast milk stool every 24 hours, is not the most reliable indicator of effective breastfeeding, although it is an important consideration. The frequency of bowel movements can vary among breastfed infants, and some babies may have several bowel movements a day, while others may have fewer, even skipping a day. The number of wet diapers is a more consistent measure of sufficient milk intake.
C. sleeps for 6 hours at a time between feedings.
sleeping for 6 hours at a time between feedings, is not an accurate indicator of effective breastfeeding in a 4-day-old newborn. Newborns typically feed frequently, at least 8-12 times in 24 hours, and they may not sleep for extended periods between feedings at this age. Frequent feeding is essential for establishing a good milk supply and ensuring the baby receives enough nutrients.
D. gains 1 to 2 ounces per week.
gaining 1 to 2 ounces per week, is also not the most reliable indicator of effective breastfeeding in the early days after birth. Weight gain can vary significantly in newborns, and a 4-day-old baby might not show the expected 1 to 2 ounces per week gain yet. Moreover, weight gain can be affected by factors other than breastfeeding, such as birth weight, initial fluid loss, and individual growth patterns.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom Maternal Newborn Proctored Exam. Take the full exam now
Full Explanation
Choice A reason:
Choice A is the correct answer because the number of wet diapers a newborn has per day is a reliable indicator of effective breastfeeding. When a baby is breastfeeding well and getting enough milk, they will have an adequate number of wet diapers, typically at least six to eight per day. The frequent wet diapers indicate that the baby is adequately hydrated, and their body is eliminating waste products as expected.
Choice B reason:
Choice B, having at least one breast milk stool every 24 hours, is not the most reliable indicator of effective breastfeeding, although it is an important consideration. The frequency of bowel movements can vary among breastfed infants, and some babies may have several bowel movements a day, while others may have fewer, even skipping a day. The number of wet diapers is a more consistent measure of sufficient milk intake.
Choice C reason:
Choice C, sleeping for 6 hours at a time between feedings, is not an accurate indicator of effective breastfeeding in a 4-day-old newborn. Newborns typically feed frequently, at least 8-12 times in 24 hours, and they may not sleep for extended periods between feedings at this age. Frequent feeding is essential for establishing a good milk supply and ensuring the baby receives enough nutrients.
Choice D reason:
Choice D, gaining 1 to 2 ounces per week, is also not the most reliable indicator of effective breastfeeding in the early days after birth. Weight gain can vary significantly in newborns, and a 4-day-old baby might not show the expected 1 to 2 ounces per week gain yet. Moreover, weight gain can be affected by factors other than breastfeeding, such as birth weight, initial fluid loss, and individual growth patterns.
Similar Questions
A woman received 50 mcg of fentanyl intravenously 1 hour before delivery. What drug should the nurse have readily available?
A. Nalbuphine (Nubain).
Nalbuphine (Nubain) is an opioid analgesic that is used to treat moderate to severe pain. It is not an antidote for fentanyl overdose and may cause respiratory depression in the newborn.
B. Naloxone (Narcan).
Nalbuphine (Nubain) is an opioid analgesic that is used to treat moderate to severe pain. It is not an antidote for fentanyl overdose and may cause respiratory depression in the newborn.
C. Butorphanol (Stadol).
Butorphanol (Stadol) is an opioid analgesic that is used to treat moderate to severe pain. It is not an antidote for fentanyl overdose and may cause respiratory depression in the newborn. •
D. Promethazine (Phenergan).
Naloxone (Narcan) is an opioid antagonist that is used to reverse the effects of opioid overdose. It can rapidly restore normal respiration in the newborn who has been exposed to fentanyl. This is the correct choice.
Full Explanation
A. Nalbuphine (Nubain): Nalbuphine is an opioid agonist-antagonist, which can be used to treat moderate to severe pain. However, it is not specifically used to reverse the effects of fentanyl. Administering Nalbuphine could potentially complicate the situation by introducing another opioid into the system.
B. Naloxone (Narcan): Naloxone is an opioid antagonist that rapidly reverses the effects of opioids like fentanyl. It is the standard treatment for opioid overdose and can quickly restore normal respiration in a person whose breathing has slowed or stopped due to opioid use. This makes it the most appropriate drug to have readily available in this scenario.
C. Butorphanol (Stadol):Butorphanol is another opioid agonist-antagonist used for pain relief. Similar to Nalbuphine, it is not used to reverse opioid effects and could complicate the patient's condition by adding another opioid to the system.
D. Promethazine (Phenergan): Promethazine is an antihistamine used to treat nausea, vomiting, and allergies. It does not have any properties that would counteract the effects of fentanyl. Therefore, it would not be useful in reversing opioid-induced respiratory depression.
The correct answer is choice A, which is to ensure that conductive heat loss from the infant is minimal
A. ensure that conductive heat loss from the infant is minimal
Placing a covering on the scale tray when weighing an infant helps to ensure that conductive heat loss from the infant is minimal. Newborns and infants are especially vulnerable to temperature changes, and maintaining their body temperature is crucial for their well-being. By placing a covering, such as a soft cloth or blanket, on the scale tray, the nurse creates a barrier between the infant's skin and the cold surface of the scale. This reduces the risk of heat loss from direct contact with the scale, helping to keep the baby comfortable and preventing any potential adverse effects from exposure to low temperatures during the weighing process.
B. compensate for the negative weight balance to ensure the correct weight
Choice B, compensating for the negative weight balance to ensure the correct weight, is not the primary reason for using a covering on the scale tray. The negative weight balance, if any, would be minimal and not significant enough to affect the accuracy of the infant's weight measurement. The main concern when using a scale for weighing infants is to ensure their comfort and safety during the process.
C. avoid causing multiple startle (Moro) reflexes when weighing
Choice C, avoiding causing multiple startle (Moro) reflexes when weighing, is not the main reason for using a covering on the scale tray. The Moro reflex is a normal startle response in infants and is not typically affected by whether or not a covering is placed on the scale tray. The nurse can support the infant appropriately during weighing to minimize any startle reflexes, regardless of whether a covering is used.
D. avoid contaminating the nurse's hands with blood or other body substances
Choice D, avoiding contaminating the nurse's hands with blood or other body substances, is not directly related to using a covering on the scale tray. The primary purpose of using a covering is to minimize heat loss, as explained in Choice A. However, it is standard practice for healthcare professionals to wear gloves when handling blood or body substances to prevent any potential transmission of infections, ensuring both the nurse's and the infant's safety.
Full Explanation
Choice A reason:
Placing a covering on the scale tray when weighing an infant helps to ensure that conductive heat loss from the infant is minimal. Newborns and infants are especially vulnerable to temperature changes, and maintaining their body temperature is crucial for their well-being. By placing a covering, such as a soft cloth or blanket, on the scale tray, the nurse creates a barrier between the infant's skin and the cold surface of the scale. This reduces the risk of heat loss from direct contact with the scale, helping to keep the baby comfortable and preventing any potential adverse effects from exposure to low temperatures during the weighing process.
Choice B reason:
Choice B, compensating for the negative weight balance to ensure the correct weight, is not the primary reason for using a covering on the scale tray. The negative weight balance, if any, would be minimal and not significant enough to affect the accuracy of the infant's weight measurement. The main concern when using a scale for weighing infants is to ensure their comfort and safety during the process.
Choice C reason:
Choice C, avoiding causing multiple startle (Moro) reflexes when weighing, is not the main reason for using a covering on the scale tray. The Moro reflex is a normal startle response in infants and is not typically affected by whether or not a covering is placed on the scale tray.
The nurse can support the infant appropriately during weighing to minimize any startle reflexes, regardless of whether a covering is used.
Choice D reason:
Choice D, avoiding contaminating the nurse's hands with blood or other body substances, is not directly related to using a covering on the scale tray. The primary purpose of using a covering is to minimize heat loss, as explained in Choice A. However, it is standard practice for healthcare professionals to wear gloves when handling blood or body substances to prevent any potential transmission of infections, ensuring both the nurse's and the infant's safety.
The main nursing observations of the woman who receives epidural or intrathecal opioids are for all except
A. delayed respiratory depression.
Delayed respiratory depression is not one of the main nursing observations for a woman who receives epidural or intrathecal opioids. Epidural and intrathecal opioids are administered for pain relief during labor or after certain surgeries, and they act locally within the spinal cord to block pain signals. Unlike systemic opioids, which can cause respiratory depression when given in high doses, epidural and intrathecal opioids have a more limited systemic effect, reducing the risk of respiratory depression. Therefore, monitoring for delayed respiratory depression is not a primary concern in this context.
B. inability to move lower extremities.
Choice B is a valid nursing observation for a woman who receives epidural or intrathecal opioids. These opioids can cause temporary paralysis or weakness in the lower extremities as a side effect of their action on the nerves in the spinal cord. Nurses need to assess the woman's ability to move her lower extremities and ensure her safety and comfort while this effect is present.
C. pruritus.
Choice C is a valid nursing observation for a woman who receives epidural or intrathecal opioids. Pruritus, which refers to itching or a sensation of itchiness, is a common side effect of opioids, including those administered via epidural or intrathecal routes. The nurse should assess the woman for any signs of pruritus and manage it appropriately if it occurs.
D. nausea and vomiting.
Choice D is a valid nursing observation for a woman who receives epidural or intrathecal opioids. Nausea and vomiting are common side effects of opioids, and they can occur after receiving these medications via epidural or intrathecal routes. The nurse should monitor the woman for any signs of nausea and vomiting and provide supportive care if needed.
Full Explanation
The correct answer is choice A, delayed respiratory depression.
Choice A reason:
Delayed respiratory depression is not one of the main nursing observations for a woman who receives epidural or intrathecal opioids. Epidural and intrathecal opioids are administered for pain relief during labor or after certain surgeries, and they act locally within the spinal cord to block pain signals. Unlike systemic opioids, which can cause respiratory depression when given in high doses, epidural and intrathecal opioids have a more limited systemic effect, reducing the risk of respiratory depression. Therefore, monitoring for delayed respiratory depression is not a primary concern in this context.
Choice B reason:
Choice B is a valid nursing observation for a woman who receives epidural or intrathecal opioids. These opioids can cause temporary paralysis or weakness in the lower extremities as a side effect of their action on the nerves in the spinal cord. Nurses need to assess the woman's ability to move her lower extremities and ensure her safety and comfort while this effect is present.
Choice C reason:
Choice C is a valid nursing observation for a woman who receives epidural or intrathecal opioids. Pruritus, which refers to itching or a sensation of itchiness, is a common side effect of opioids, including those administered via epidural or intrathecal routes. The nurse should assess the woman for any signs of pruritus and manage it appropriately if it occurs.
Choice D reason:
Choice D is a valid nursing observation for a woman who receives epidural or intrathecal opioids. Nausea and vomiting are common side effects of opioids, and they can occur after receiving these medications via epidural or intrathecal routes. The nurse should monitor the woman for any signs of nausea and vomiting and provide supportive care if needed.