Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse is caring for a newborn born at 31 weeks' gestation. Which assessment finding should the nurse anticipate?
A. Sole creases on heels
Sole creases on heels. Sole creases are a sign of maturity and are usually present in full-term infants, not preterm.
B. Ruddy skin color
Ruddy skin color. This is more common in infants with polycythemia or those who are small for gestational age, not specifically linked to prematurity.
C. Flexion of all four (4) extremities
Flexion of all four extremities. Premature infants typically have less muscle tone and may exhibit less flexion, often appearing more limp or having extended extremities.
D. Scant amount of vernix caseosa
Scant amount of vernix caseosa. Premature infants typically have more vernix caseosa, which protects their delicate skin in utero. The amount decreases closer to full term, but at 31 weeks, there may still be a moderate amount.
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Full Explanation
A. Sole creases on heels. Sole creases are a sign of maturity and are usually present in full-term infants, not preterm.
B. Ruddy skin color. This is more common in infants with polycythemia or those who are small for gestational age, not specifically linked to prematurity.
C. Flexion of all four extremities. Premature infants typically have less muscle tone and may exhibit less flexion, often appearing more limp or having extended extremities.
D. Scant amount of vernix caseosa. Premature infants typically have more vernix caseosa, which protects their delicate skin in utero. The amount decreases closer to full term, but at 31 weeks, there may still be a moderate amount.
Similar Questions
The nurse knows that which of the following is not a cause of mastitis?
A. Oversupply of milk
Oversupply of milk. This can lead to milk stasis and blockage, which can increase the risk of mastitis.
B. Gradual weaning of breastfeeding
Gradual weaning of breastfeeding. Gradual weaning typically helps reduce the risk of mastitis because it allows the milk supply to decrease slowly and naturally without engorgement or blockage.
C. Infrequent, inconsistent feedings
Infrequent, inconsistent feedings. This can lead to milk stasis and is a common cause of mastitis.
D. Cracks or fissures of the nipples
Cracks or fissures of the nipples. These can provide an entry point for bacteria, leading to infection and mastitis.
Full Explanation
A. Oversupply of milk. This can lead to milk stasis and blockage, which can increase the risk of mastitis.
B. Gradual weaning of breastfeeding. Gradual weaning typically helps reduce the risk of mastitis because it allows the milk supply to decrease slowly and naturally without engorgement or blockage.
C. Infrequent, inconsistent feedings. This can lead to milk stasis and is a common cause of mastitis.
D. Cracks or fissures of the nipples. These can provide an entry point for bacteria, leading to infection and mastitis.
A child with a heart defect is placed on a maintenance dose of Lanoxin elixir. The ordered dose is 0.07mg/kg/day in 2 divided doses. The child weighs 19 pounds. What is the maximum amount of medication that will be given per dose by the nurse?
Full Explanation
Convert weight from pounds to kilograms:
19pounds÷2.2=8.64kg
Calculate the total daily dose:
0.07mg/kg/day×8.64kg=0.6048mg/day
Divide the daily dose into two doses:
0.6048mg/day÷2=0.3024mg/dose
Round off the dose to two decimal places:
0.3024mg≈0.30mg
The maximum amount of medication per dose is 0.3 mg.
The nurse identifies the following assessment findings in a client who is 36 weeks' gestation. Which should be immediately reported to the provider?
A. O negative blood type
O negative blood type. This is significant for Rh incompatibility if the fetus is Rh-positive, but it is managed through routine prenatal care and does not require immediate intervention at 36 weeks.
B. Blood pressure 144/94 mm/Hg in left arm
Blood pressure 144/94 mmHg in left arm. This finding is concerning because it may indicate the development of preeclampsia, which requires immediate medical attention due to the potential risks to both the mother and fetus.
C. Positive rubella serum antibody titer
Positive rubella serum antibody titer. A positive titer indicates immunity to rubella, which is a good finding in pregnancy and not a concern.
D. Copious leukorrhea
Copious leukorrhea. This is common in late pregnancy and typically not a cause for concern unless it is accompanied by signs of infection or rupture of membranes.
Full Explanation
A. O negative blood type. This is significant for Rh incompatibility if the fetus is Rh-positive, but it is managed through routine prenatal care and does not require immediate intervention at 36 weeks.
B. Blood pressure 144/94 mmHg in left arm. This finding is concerning because it may indicate the development of preeclampsia, which requires immediate medical attention due to the potential risks to both the mother and fetus.
C. Positive rubella serum antibody titer. A positive titer indicates immunity to rubella, which is a good finding in pregnancy and not a concern.
D. Copious leukorrhea. This is common in late pregnancy and typically not a cause for concern unless it is accompanied by signs of infection or rupture of membranes.