Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
After breast-feeding 10 minutes at each breast, a new mother calls the nurse to the postpartum room to help change the newborn's diaper. As the mother begins the diaper change, the newborn spits up the breast milk. What action should the nurse implement first?
A. Place the newborn in a position with the head lower than the feet.
Place the newborn in a position with the head lower than the feet:This position might be used in cases of choking or difficulty breathing, but it's not typically the first response to spitting up.
B. Turn the newborn to the side and bulb suction the mouth and nares.
Turn the newborn to the side and bulb suction the mouth and nares:Suctioning might be necessary if there's difficulty breathing or if there's an excessive amount of mucus. However, for typical spit-up, this might be an unnecessary intervention.
C. Wipe away the spit-up and assist the mother with the diaper change
Wipe away the spit-up and assist the mother with the diaper change: Addressing the immediate concern by cleaning up and assisting with the diaper change is a reasonable first step, but it doesn't directly address the spit-up.
D. Sit the newborn upright and burp by rubbing or patting the upper back
Sit the newborn upright and burp by rubbing or patting the upper back:This is a common and appropriate action after feeding to help release any trapped air and prevent or alleviate spit-up.
This question is an excerpt from Nurse Dive's nursing test bank - Samuel Merrit University Oaklands Hesi Maternity (Labor and Delivery) Proctored Exam. Take the full exam now
Full Explanation
A. Place the newborn in a position with the head lower than the feet:
This position might be used in cases of choking or difficulty breathing, but it's not typically the first response to spitting up.
B. Turn the newborn to the side and bulb suction the mouth and nares:
Suctioning might be necessary if there's difficulty breathing or if there's an excessive amount of mucus. However, for typical spit-up, this might be an unnecessary intervention.
C. Wipe away the spit-up and assist the mother with the diaper change:
Addressing the immediate concern by cleaning up and assisting with the diaper change is a reasonable first step, but it doesn't directly address the spit-up.
D. Sit the newborn upright and burp by rubbing or patting the upper back:
This is a common and appropriate action after feeding to help release any trapped air and prevent or alleviate spit-up.
Similar Questions
What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?
A. Level of pain sensation.
Level of pain sensation: This is important for assessing the effectiveness of the epidural anesthesia, but it's not the most critical assessment immediately after administration.
B. Variability of fetal heart rate
Variability of fetal heart rate: Monitoring fetal heart rate is always important, but immediately following epidural administration, the maternal blood pressure is a more immediate concern.
C. Maternal blood pressure
Maternal blood pressure: This is the most critical assessment after epidural administration. Epidurals can cause a sudden drop in blood pressure, which may affect blood flow to the baby.
D. Station of presenting part
Station of presenting part: The station of the presenting part (the position of the baby's head in relation to the ischial spines) is important for assessing progress in labor, but it's not the most crucial assessment immediately after epidural administration.
Full Explanation
Level of pain sensation:
This is important for assessing the effectiveness of the epidural anesthesia, but it's not the most critical assessment immediately after administration.
Variability of fetal heart rate:
Monitoring fetal heart rate is always important, but immediately following epidural administration, the maternal blood pressure is a more immediate concern.
Maternal blood pressure:
This is the most critical assessment after epidural administration. Epidurals can cause a sudden drop in blood pressure, which may affect blood flow to the baby.
Station of presenting part:
The station of the presenting part (the position of the baby's head in relation to the ischial spines) is important for assessing progress in labor, but it's not the most crucial assessment immediately after epidural administration.
The nurse is providing preconception counseling. Which supplement should the nurse recommend to help prevent the occurrence of anencephaly?
A. Calcium.
Calcium: Calcium is essential for the development of fetal bones and teeth, but it is not specifically linked to preventing neural tube defects like anencephaly.
B. Iron
Iron: Iron is crucial for preventing anemia in pregnancy, supporting increased blood volume. However, it is not directly associated with preventing neural tube defects.
C. Folic acid.
Folic acid: Folic acid is vital for preventing neural tube defects, including anencephaly. It's recommended for women of childbearing age and especially during the early stages of pregnancy.
D. Vitamin D.
Vitamin D: Vitamin D is important for bone health, but its primary function is not directly related to preventing neural tube defects like anencephaly.
Full Explanation
Calcium:
Calcium is essential for the development of fetal bones and teeth, but it is not specifically linked to preventing neural tube defects like anencephaly.
Iron:
Iron is crucial for preventing anemia in pregnancy, supporting increased blood volume. However, it is not directly associated with preventing neural tube defects.
Folic acid:
Folic acid is vital for preventing neural tube defects, including anencephaly. It's recommended for women of childbearing age and especially during the early stages of pregnancy.
Vitamin D:
Vitamin D is important for bone health, but its primary function is not directly related to preventing neural tube defects like anencephaly.
A client who delivered vaginally 2 days ago states that she wants to resume using her diaphragm for birth control. What information should the nurse share with her?
A. The diaphragm must be refitted after childbirth
The diaphragm must be refitted after childbirth: This statement is correct. After childbirth, especially vaginal delivery, there can be changes in the size and tone of the vagina. Therefore, it's important to be refitted for a diaphragm after giving birth.
B. The most effective form of contraception is a diaphragm
The most effective form of contraception is a diaphragm: This statement is not accurate. While the diaphragm is a reversible and user-controlled method, its effectiveness can vary. It requires correct and consistent use to be effective.
C. The diaphragm should be inserted 2 to 4 hours before intercourse.
The diaphragm should be inserted 2 to 4 hours before intercourse: This statement is partially correct. The diaphragm should be inserted no more than 2 hours before intercourse and should be left in place for at least 6 hours after intercourse.
D. Vaseline lubricant can be used when inserting the diaphragm
This statement is incorrect. Oil-based lubricants, including Vaseline, can damage latex diaphragms. Water-based lubricants are recommended for use with diaphragms
Full Explanation
The diaphragm must be refitted after childbirth:
This statement is correct. After childbirth, especially vaginal delivery, there can be changes in the size and tone of the vagina. Therefore, it's important to be refitted for a diaphragm after giving birth.
The most effective form of contraception is a diaphragm:
This statement is not accurate. While the diaphragm is a reversible and user-controlled method, its effectiveness can vary. It requires correct and consistent use to be effective.
The diaphragm should be inserted 2 to 4 hours before intercourse:
This statement is partially correct. The diaphragm should be inserted no more than 2 hours before intercourse and should be left in place for at least 6 hours after intercourse.
Vaseline lubricant can be used when inserting the diaphragm:
This statement is incorrect. Oil-based lubricants, including Vaseline, can damage latex diaphragms. Water-based lubricants are recommended for use with diaphragms