Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
An infant's axillary temperature is 35.9C (96.6F). The priority nursing action is to:
A. chart the normal axillary temperature.
Charting the normal axillary temperature is not the priority in this situation. The infant's temperature is subnormal, indicating hypothermia, which requires immediate intervention.
B. recheck the infant's temperature rectally.
Rechecking the infant's temperature rectally may provide a more accurate reading, but it is not the priority action at this moment. The infant's low temperature indicates the need for immediate warming to prevent further complications.
C. place the infant in a radiant warmer.
Placing the infant in a radiant warmer is the priority nursing action. The axillary temperature of 35.9°C (96.6°F) is below the normal range for a newborn, which is around 36.5-37.5°C (97.7-99.5°F). Hypothermia in newborns can be dangerous and lead to respiratory distress, metabolic problems, and other complications. A radiant warmer provides a controlled heat source to warm the infant and stabilize their body temperature.
D. have the mother breastfeed the infant.
Having the mother breastfeed the infant may help provide warmth and comfort, but it is not the priority action. The immediate concern is to raise the infant's body temperature to a safe range using a radiant warmer.
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:
Charting the normal axillary temperature is not the priority in this situation. The infant's temperature is subnormal, indicating hypothermia, which requires immediate intervention.
Choice B reason:
Rechecking the infant's temperature rectally may provide a more accurate reading, but it is not the priority action at this moment. The infant's low temperature indicates the need for immediate warming to prevent further complications.
Choice C reason:
Placing the infant in a radiant warmer is the priority nursing action. The axillary temperature of 35.9°C (96.6°F) is below the normal range for a newborn, which is around 36.5-37.5°C (97.7-99.5°F). Hypothermia in newborns can be dangerous and lead to respiratory distress, metabolic problems, and other complications. A radiant warmer provides a controlled heat source to warm the infant and stabilize their body temperature.
Choice D reason:
Having the mother breastfeed the infant may help provide warmth and comfort, but it is not the priority action. The immediate concern is to raise the infant's body temperature to a safe range using a radiant warmer.
Similar Questions
A nurse is caring for a client 2 hours after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-minute period. Which of the following is the priority nursing intervention at this time?
A. Assist the client on a bedpan to urinate.
Assisting the client on a bedpan to urinate is important for assessing urinary output and preventing bladder distension. However, in this situation, the priority is to assess and manage postpartum hemorrhage, which is indicated by the excessive bleeding.
B. Increase the client's fluid intake.
Increasing the client's fluid intake is generally a good measure for promoting hydration and maintaining blood volume. However, it is not the priority in this scenario of excessive postpartum bleeding.
C. Palpate the client's uterine fundus.
Palpating the client's uterine fundus is the priority nursing intervention at this time. The excessive bleeding indicated by saturating two perineal pads in a 30-minute period suggests postpartum hemorrhage, which can result from uterine atony (failure of the uterus to contract adequately after childbirth). Palpating the fundus allows the nurse to assess if the uterus is firm or boggy, and if it is not contracting properly, immediate interventions can be initiated to control the bleeding.
D. Prepare to administer oxytocic medication.
Preparing to administer oxytocic medication (such as oxytocin) can help stimulate uterine contractions and prevent or manage postpartum hemorrhage. However, the priority is to first assess the uterine fundus and confirm the cause of the excessive bleeding before administering any medication.
Full Explanation
Choice A reason:
Assisting the client on a bedpan to urinate is important for assessing urinary output and preventing bladder distension. However, in this situation, the priority is to assess and manage postpartum hemorrhage, which is indicated by the excessive bleeding.
Choice B reason:
Increasing the client's fluid intake is generally a good measure for promoting hydration and maintaining blood volume. However, it is not the priority in this scenario of excessive postpartum bleeding.
Choice C reason:
Palpating the client's uterine fundus is the priority nursing intervention at this time. The excessive bleeding indicated by saturating two perineal pads in a 30-minute period suggests postpartum hemorrhage, which can result from uterine atony (failure of the uterus to contract adequately after childbirth). Palpating the fundus allows the nurse to assess if the uterus is firm or boggy, and if it is not contracting properly, immediate interventions can be initiated to control the bleeding.
Choice D reason:
Preparing to administer oxytocic medication (such as oxytocin) can help stimulate uterine contractions and prevent or manage postpartum hemorrhage. However, the priority is to first assess the uterine fundus and confirm the cause of the excessive bleeding before administering any medication.
A client in latent phase of labor for the past 12 hours is requesting medication to help her rest.
A. Fentanyl
Fentanyl: a synthetic opioid that is used for pain relief and sedation. It is fast-acting and potent, but can cause respiratory depression and nausea.
B. Meperidine.
Meperidine: a synthetic opioid that is used for pain relief and sedation. It is less potent than fentanyl, but can cause seizures and serotonin syndrome. • C. Morphine: a natural opioid that is used for pain relief and sedation. It is less potent than fentanyl, but can cause respiratory depression and itching
C. Morphine.
Morphine: a natural opioid that is used for pain relief and sedation. It is less potent than fentanyl but can cause respiratory depression and itching.
D. Secobarbital.
Secobarbital: a barbiturate that is used for sedation and anesthesia. It is not an opioid, but can cause respiratory depression and addiction.
E. Secobarbital.
Full Explanation
The question is about a client who has been in the latent phase of labor for 12 hours and wants some medication to help her rest. The nurse has to predict which medication the healthcare provider will prescribe. The choices are:. • A. Fentanyl: a synthetic opioid that is used for pain relief and sedation. It is fast-acting and potent, but can cause respiratory depression and nausea. • B. Meperidine: a synthetic opioid that is used for pain relief and sedation. It is less potent than fentanyl, but can cause seizures and serotonin syndrome. • C. Morphine: a natural opioid that is used for pain relief and sedation. It is less potent than fentanyl, but can cause respiratory depression and itching. • D. Secobarbital: a barbiturate that is used for sedation and anesthesia. It is not an opioid, but can cause respiratory depression and addiction.
After teaching a pregnant woman about the hormones produced by the placenta, the nurse determines that the teaching was successful when the woman identifies which hormone produced as being the basis for pregnancy tests?
A. Human placental lactogen (hPL).
Human placental lactogen (hPL) is a hormone produced by the placenta that promotes mammary gland growth for lactation. It also helps regulate maternal glucose and lipid metabolism. However, hPL is not the basis for pregnancy tests, as it is not produced by the fertilized egg and does not maintain the corpus luteum.
B. Estrogen (estriol).
Estrogen (estriol) is a steroid hormone produced by the placenta that stimulates the growth of the uterus and allows it to contract by countering the effect of progesterone. It also prepares the breasts for milk production and enhances fetal organ development. However, estrogen is not the basis for pregnancy tests, as it is not produced by the fertilized egg and does not maintain the corpus luteum.
C. Progesterone (progestin).
Progesterone (progestin) is a steroid hormone produced by the ovaries and by the placenta during pregnancy. Progesterone supports the lining of the uterus, which provides the environment for the fetus and the placenta to grow. It also prevents the shedding of the lining and suppresses uterine contractions, which are important in preventing labor from occurring before the end of pregnancy. However, progesterone is not the basis for pregnancy tests, as it is not produced by the fertilized egg and does not maintain the corpus luteum.
D. Human chorionic gonadotropin (hCG).
Human chorionic gonadotropin (hCG) is a hormone produced by the fertilized egg after it implants in the uterus. hCG helps maintain the corpus luteum during the early stages of pregnancy, which is essential for producing progesterone. hCG levels rise rapidly in the first few weeks of pregnancy and can be detected in urine or blood samples. Therefore, hCG is the basis for pregnancy tests, as it indicates that a fertilization and implantation have occurred.
Full Explanation
A. Human placental lactogen (hPL) is a hormone produced by the placenta that helps regulate the metabolism of the mother and fetus, but it is not used as the basis for pregnancy tests. It plays a role in modulating the metabolic state of the mother during pregnancy to facilitate the energy supply of the fetus.
B. Estrogen (estriol) is another hormone produced by the placenta, which is important for maintaining pregnancy and preparing the body for childbirth. However, it is not the hormone detected by pregnancy tests. Estriol levels increase significantly during pregnancy but are not used as a marker for pregnancy tests.
C. Progesterone (progestin) is crucial for maintaining the uterine lining and supporting early pregnancy. While it is essential for a successful pregnancy, it is not the hormone that pregnancy tests detect. Progesterone helps prevent uterine contractions and supports the endometrium.
D. Human chorionic gonadotropin (hCG) is the hormone detected by pregnancy tests. It is produced by the placenta shortly after the embryo attaches to the uterine lining. The presence of hCG in the blood or urine is a reliable indicator of pregnancy, which is why it is the basis for pregnancy tests.