Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A. Assess the client’s perineal area for signs of a perineal hematoma.
While a perineal hematoma can lead to increased WBC count, there is no indication of such a complication, making this assessment less immediate.
B. Assess the client’s temperature, pulse, and respirations every 4 hours.
Assessing vital signs is an important part of routine postpartum care. Still, a white blood cell count of 15,000/mm is within a normal range for a woman within the first 24-48 hours after delivery and is not necessarily indicative of infection.
C. Notify the healthcare provider, since this finding is indicative of infection.
While an elevated WBC can indicate infection, a postpartum woman's white blood cell count can be normally elevated up to 20,000/mm due to the stress of labor and delivery. Checking a differential will provide a more accurate breakdown of different types of white blood cells for a more precise assessment.
D. Check the differential, since the WBC is normal for this client.
A normal WBC in a postpartum client ranges from (12,000- 20, 000/mm. Checking the white blood cell differential helps determine the specific types of WBCs present and gives more information as to whether the elevation is the body's normal response to childbirth or a sign of infection.
This question is an excerpt from Nurse Dive's nursing test bank - Care Hope College RN HESI Maternity Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale
While a perineal hematoma can lead to increased WBC count, there is no indication of such a complication, making this assessment less immediate.
Choice B rationale
Assessing vital signs is an important part of routine postpartum care. Still, a white blood cell count of 15,000/mm is within a normal range for a woman within the first 24-48 hours after delivery and is not necessarily indicative of infection.
Choice C rationale
While an elevated WBC can indicate infection, a postpartum woman's white blood cell count can be normally elevated up to 20,000/mm due to the stress of labor and delivery. Checking a differential will provide a more accurate breakdown of different types of white blood cells for a more precise assessment.
Choice D rationale
A normal WBC in a postpartum client ranges from (12,000- 20, 000/mm. Checking the white blood cell differential helps determine the specific types of WBCs present and gives more information as to whether the elevation is the body's normal response to childbirth or a sign of infection.
Similar Questions
A neonate, who is one day old, develops a cephalhematoma.
Which common complication should the nurse assess this neonate for?
A. Poor appetite.
Poor appetite can be a symptom of many neonatal conditions, but it's not the most common complication specifically associated with cephalhematoma.
B. Jaundice.
Cephalhematomas are caused by the rupture of blood vessels between the skull and periosteum, resulting in a blood collection. The breakdown of red blood cells in this trapped blood can lead to the release of bilirubin, increasing an infant's risk for hyperbilirubinemia and jaundice.
C. Hypoglycemia.
Hypoglycemia is a potential concern in neonates but is not directly related to cephalhematoma.
D. Brain damage.
While brain damage is a serious potential complication in cases of severe skull trauma, it's not typically associated with cephalhematoma alone. Cephalhematomas usually resolve on their own without long-term consequences.
Full Explanation
Choice A rationale
Poor appetite can be a symptom of many neonatal conditions, but it's not the most common complication specifically associated with cephalhematoma.
Choice B rationale
Cephalhematomas are caused by the rupture of blood vessels between the skull and periosteum, resulting in a blood collection. The breakdown of red blood cells in this trapped blood can lead to the release of bilirubin, increasing an infant's risk for hyperbilirubinemia and jaundice.
Choice C rationale
Hypoglycemia is a potential concern in neonates but is not directly related to cephalhematoma.
Choice D rationale
While brain damage is a serious potential complication in cases of severe skull trauma, it's not typically associated with cephalhematoma alone. Cephalhematomas usually resolve on their own without long-term consequences.
A client, who is three days postpartum and formula feeding her newborn, reports experiencing painful, hard, and full breasts to the nurse.
What recommendation should the nurse provide?
A. Pump breasts every few hours.
Pumping breasts every few hours can stimulate milk production, which is not the goal for a formula-feeding mother.
B. Latch the baby on to feed for just a few minutes.
Latching the baby on to feed for just a few minutes can also stimulate milk production, which is not the goal for a formula-feeding mother.
C. Change breast pads often.
Changing breast pads often is a good practice for breastfeeding mothers to maintain hygiene and prevent infections, but it does not directly address the issue of painful, hard, and full breasts in a formula-feeding mother.
D. Wear a form-fitting bra for the next couple of days.
Wearing a form-fitting bra for the next couple of days can provide support and help reduce the discomfort associated with engorgement in a formula-feeding mother.
Full Explanation
Choice A rationale
Pumping breasts every few hours can stimulate milk production, which is not the goal for a formula-feeding mother.
Choice B rationale
Latching the baby on to feed for just a few minutes can also stimulate milk production, which is not the goal for a formula-feeding mother.
Choice C rationale
Changing breast pads often is a good practice for breastfeeding mothers to maintain hygiene and prevent infections, but it does not directly address the issue of painful, hard, and full breasts in a formula-feeding mother.
Choice D rationale
Wearing a form-fitting bra for the next couple of days can provide support and help reduce the discomfort associated with engorgement in a formula-feeding mother.
A 16-year-old client, who is pregnant for the first time and has no children, has been admitted to the hospital with a diagnosis of eclampsia.
She is not currently convulsing.
What intervention should the nurse plan to include in this client’s nursing care plan?
A. Monitor blood pressure, pulse, and respirations every 4 hours.
While monitoring vital signs is important in a client with eclampsia, it should be done more frequently than every 4 hours due to the risk of seizures and other complications.
B. Keep an airway at the bedside.
Keeping an airway at the bedside is crucial for a client with eclampsia. If a seizure occurs, the airway can be used to ensure the client’s airway remains open.
C. Allow liberal family visitation.
Liberal family visitation may not be appropriate for a client with eclampsia who needs a quiet and stress-free environment to prevent triggering seizures.
D. Assess temperature every hour.
Assessing temperature every hour is not specifically related to the care of a client with eclampsia.
Full Explanation
Choice A rationale
While monitoring vital signs is important in a client with eclampsia, it should be done more frequently than every 4 hours due to the risk of seizures and other complications.
Choice B rationale
Keeping an airway at the bedside is crucial for a client with eclampsia. If a seizure occurs, the airway can be used to ensure the client’s airway remains open.
Choice C rationale
Liberal family visitation may not be appropriate for a client with eclampsia who needs a quiet and stress-free environment to prevent triggering seizures.
Choice D rationale
Assessing temperature every hour is not specifically related to the care of a client with eclampsia.