Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Parents express concern about the milia on the face and nose of their baby. The nurse's most helpful response would be to instruct the parents to:
A. Squeeze out the white material after cleansing the face.
This is incorrect because squeezing out the white material can damage the skin and cause infection or scarring.
B. Contact a pediatric dermatologist for topical medication
This is incorrect because contacting a pediatric dermatologist is unnecessary and expensive for a benign condition that resolves by itself.
C. Leave the milia alone: it will disappear spontaneously. No treatment is needed.
Leave the milia alone: it will disappear spontaneously. No treatment is needed. Milia are small, white cysts that form on the skin, usually on the face, nose, or cheeks of newborns. They are harmless and very common, affecting about half of all healthy infants. They are caused by dead skin cells trapped in pockets of the skin or mouth. They are not a type of acne and are not related to breastfeeding or formula feeding. They usually go away on their own within a few weeks or months without any intervention.
D. Wash the baby's face with a mild astringent several times a day.
Thisis incorrect because washing the baby's face with a mild astringent can irritate the skin and make the milia worse.
This question is an excerpt from Nurse Dive's nursing test bank - Postpartum AMD Newborn Care Proctored Exam. Take the full exam now
Full Explanation
Leave the milia alone: it will disappear spontaneously. No treatment is needed. Milia are small, white cysts that form on the skin, usually on the face, nose, or cheeks of newborns. They are harmless and very common, affecting about half of all healthy infants. They are caused by dead skin cells trapped in pockets of the skin or mouth. They are not a type of acne and are not related to breastfeeding or formula feeding. They usually go away on their own within a few weeks or months without any intervention.
Choice A is incorrect because squeezing out the white material can damage the skin and cause infection or scarring.
Choice B is incorrect because contacting a pediatric dermatologist is unnecessary and expensive for a benign condition that resolves by itself.
Choice D is incorrect because washing the baby's face with a mild astringent can irritate the skin and make the milia worse.
Similar Questions
The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. The nurse should next assess:
A. Blood pressure
Blood pressure is not the next assessment because it is not related to the position and tone of the uterus. Blood pressure may be affected by blood loss, but it is not a priority in this situation.
B. Amount of lochia
Amount of lochia is not the next assessment because it is not related to the position and tone of the uterus. Lochia may be increased or decreased depending on the uterine contraction, but it is not a priority in this situation.
C. Fulness of the bladder
Fullness of the bladder. A boggy uterus with the fundus above the umbilicus and deviated to the side indicates that the uterus is not contracting properly and may be displaced by a full bladder. A full bladder can interfere with uterine involution and increase the risk of postpartum hemorrhage. The nurse should assess the bladder and assist the patient to empty it if needed.
D. Level of pain
Level of pain is not the next assessment because it is not related to the position and tone of the uterus. Pain may be present due to uterine cramping or other factors, but it is not a priority in this situation.
Full Explanation
Fullness of the bladder. A boggy uterus with the fundus above the umbilicus and deviated to the side indicates that the uterus is not contracting properly and may be displaced by a full bladder. A full bladder can interfere with uterine involution and increase the risk of postpartum hemorrhage. The nurse should assess the bladder and assist the patient to empty it if needed.
Choice A. Blood pressure is not the next assessment because it is not related to the position and tone of the uterus. Blood pressure may be affected by blood loss, but it is not a priority in this situation.
Choice B. Amount of lochia is not the next assessment because it is not related to the position and tone of the uterus. Lochia may be increased or decreased depending on the uterine contraction, but it is not a priority in this situation.
Choice D. Level of pain is not the next assessment because it is not related to the position and tone of the uterus. Pain may be present due to uterine cramping or other factors, but it is not a priority in this situation.
A nurse is caring for a client who is 4 hr postpartum. The nurse finds a small amount of lochia rubra on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?
A. Increase the rate of IV fluids.
Increasing the rate of the IV fluids is not necessary because the client's fundus is firm and midline, indicating that the uterus is contracting well and preventing excessive bleeding.
B. Assist the client to ambulate.
Assisting the client to ambulate is not advisable because it can increase the lochia flow and cause fainting or dizziness due to blood loss.
C. Perform fundal massage.
Performing fundal massage is not indicated because the fundus is already firm and midline, meaning that the uterus is adequately contracted. Massaging a firm fundus can cause pain and discomfort to the client.
D. Check for blood under the client's buttock.
Check for blood under the client's buttock. This is because lochia rubra is the normal vaginal discharge that occurs after childbirth, consisting of blood, mucus, and tissue from the placenta and the uterus lining. It is usually heavy for the first three to four days and can pool under the client's buttocks if they are lying down. Checking for blood under the buttock can help assess the amount of bleeding and prevent complications such as infection or hemorrhage.
Full Explanation
Check for blood under the client's buttock. This is because lochia rubra is the normal vaginal discharge that occurs after childbirth, consisting of blood, mucus, and tissue from the placenta and the uterus lining. It is usually heavy for the first three to four days and can pool under the client's buttocks if they are lying down. Checking for blood under the buttock can help assess the amount of bleeding and prevent complications such as infection or hemorrhage.
The other choices are not correct for the following reasons:
A. Increasing the rate of the IV fluids is not necessary because the client's fundus is firm and midline, indicating that the uterus is contracting well and preventing excessive bleeding.
B. Assisting the client to ambulate is not advisable because it can increase the lochia flow and cause fainting or dizziness due to blood loss.
C. Performing fundal massage is not indicated because the fundus is already firm and midline, meaning that the uterus is adequately contracted. Massaging a firm fundus can cause pain and discomfort to the client.
A nurse is teaching a new mother about signs of effective breastfeeding of her newborn. Which of the following information should the nurse include in the teaching?
A. Expect your baby to feed constantly the first week of life.
This is incorrect because your baby does not need to feed constantly in the first week of life. Your baby should feed at least eight times in 24 hours but may have periods of cluster feeding where they feed more frequently for a few hours.
B. Your baby can lose 5% of body weight during the first 3 days of life.
Your baby can lose 5% of body weight during the first 3 days of life. This is a normal physiological process that happens as your baby adjusts to breastfeeding and expels excess fluids. Your baby should regain this weight by 10 to 14 days of age.
C. Expect your baby to have less than 5 wet diapers per day after the fourth day of life.
This is incorrect because your baby should have more than 5 wet diapers per day after the fourth day of life. This is a sign that your baby is getting enough milk and is well-hydrated.
D. Your baby should gain 0.25 oz (7 grams) per day after the fourth day of life.
This is incorrect because your baby should gain more than 0.25 oz (7 grams) per day after the fourth day of life. The average weight gain for a breastfed baby is about 0.5 to 1 oz (14 to 28 grams) per day in the first month.
Full Explanation
Your baby can lose 5% of body weight during the first 3 days of life. This is a normal physiological process that happens as your baby adjusts to breastfeeding and expels excess fluids. Your baby should regain this weight by 10 to 14 days of age.
Choice A is incorrect because your baby does not need to feed constantly in the first week of life. Your baby should feed at least eight times in 24 hours but may have periods of cluster feeding where they feed more frequently for a few hours.
Choice C is incorrect because your baby should have more than 5 wet diapers per day after the fourth day of life. This is a sign that your baby is getting enough milk and is well-hydrated.
Choice D is incorrect because your baby should gain more than 0.25 oz (7 grams) per day after the fourth day of life. The average weight gain for a breastfed baby is about 0.5 to 1 oz (14 to 28 grams) per day in the first month.