Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse is providing preconception counseling.
Which supplement should the nurse recommend to help prevent the occurrence of anencephaly?
A. 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. 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.
C. Vitamin D.
Vitamin D is important for bone health, but its primary function is not directly related to preventing neural tube defects like anencephaly.
D. Iron.
Iron is crucial for preventing anemia in pregnancy, supporting increased blood volume. However, it is not directly associated with preventing neural tube defects.
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
Calcium is essential for the development of fetal bones and teeth, but it is not specifically linked to preventing neural tube defects like anencephaly.
Choice B rationale
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.
Choice C rationale
Vitamin D is important for bone health, but its primary function is not directly related to preventing neural tube defects like anencephaly.
Choice D rationale
Iron is crucial for preventing anemia in pregnancy, supporting increased blood volume. However, it is not directly associated with preventing neural tube defects.
Similar Questions
The nurse observes on the fetal monitor that a laboring client has a variable deceleration. What action should the nurse implement first?
A. Administer oxygen via facemask.
Administering oxygen via facemask is a common intervention for variable decelerations, but it is not the first action that should be taken.
B. Change the client’s position.
Changing the client’s position is the recommended first action for variable decelerations. Repositioning the mother, such as moving her to a lateral or knee-chest position, can relieve potential cord compression and improve fetal oxygenation.
C. Turn off the oxytocin infusion.
Turning off the oxytocin infusion is another intervention for variable decelerations, but it is not the first action that should be taken.
D. Assess cervical dilatation.
Assessing cervical dilation is not the first action that should be taken in response to variable decelerations.
Full Explanation
Choice A rationale
Administering oxygen via facemask is a common intervention for variable decelerations, but it is not the first action that should be taken.
Choice B rationale
Changing the client’s position is the recommended first action for variable decelerations. Repositioning the mother, such as moving her to a lateral or knee-chest position, can relieve potential cord compression and improve fetal oxygenation.
Choice C rationale
Turning off the oxytocin infusion is another intervention for variable decelerations, but it is not the first action that should be taken.
Choice D rationale
Assessing cervical dilation is not the first action that should be taken in response to variable decelerations.
A client who is at 10-weeks gestation calls the clinic because she has been vomiting for the past 24 hours. The nurse determines that the client has no fever.
What instruction should the nurse give to this client?
A. Remain on clear liquids until the vomiting subsides.
While remaining on clear liquids until the vomiting subsides may seem like a reasonable approach, it may not be the best course of action for a pregnant woman who has been vomiting for 24 hours. This is because prolonged vomiting can lead to dehydration and electrolyte imbalances, which can be harmful to both the mother and the fetus.
B. Take nothing by mouth until there is no more nausea.
Taking nothing by mouth until there is no more nausea is not advisable in this situation. Nausea can persist even after vomiting has stopped, and it’s important for the woman to stay hydrated and nourished.
C. Come to the clinic to be seen by a healthcare provider.
The best course of action in this situation is for the woman to come to the clinic to be seen by a healthcare provider. This is because prolonged vomiting can lead to dehydration and electrolyte imbalances, which can be harmful to both the mother and the fetus. In addition, the healthcare provider can assess the woman’s condition and provide appropriate treatment.
D. Make an appointment at the clinic if a fever occurs.
Making an appointment at the clinic if a fever occurs is not the best advice in this situation. While it’s important to seek medical attention if a fever develops, the woman should not wait for this to happen before seeking help. Prolonged vomiting can lead to dehydration and electrolyte imbalances, which can be harmful to both the mother and the fetus, and should be addressed promptly.
Full Explanation
Choice A rationale
While remaining on clear liquids until the vomiting subsides may seem like a reasonable approach, it may not be the best course of action for a pregnant woman who has been vomiting for 24 hours. This is because prolonged vomiting can lead to dehydration and electrolyte imbalances, which can be harmful to both the mother and the fetus.
Choice B rationale
Taking nothing by mouth until there is no more nausea is not advisable in this situation. Nausea can persist even after vomiting has stopped, and it’s important for the woman to stay hydrated and nourished.
Choice C rationale
The best course of action in this situation is for the woman to come to the clinic to be seen by a healthcare provider. This is because prolonged vomiting can lead to dehydration and electrolyte imbalances, which can be harmful to both the mother and the fetus. In addition, the healthcare provider can assess the woman’s condition and provide appropriate treatment.
Choice D rationale
Making an appointment at the clinic if a fever occurs is not the best advice in this situation. While it’s important to seek medical attention if a fever develops, the woman should not wait for this to happen before seeking help. Prolonged vomiting can lead to dehydration and electrolyte imbalances, which can be harmful to both the mother and the fetus, and should be addressed promptly.
The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations.
What priority issue should the nurse address to ensure the newborn’s survival?
A. Heat loss.
Heat loss is a significant concern for newborns immediately after birth. Newborns have a large surface area relative to their body weight, which makes them more susceptible to heat loss. Maintaining a warm environment is crucial to prevent hypothermia, which can lead to complications such as hypoglycemia and respiratory distress.
B. Hypoglycemia.
While hypoglycemia is a concern in newborns, especially those born to mothers with diabetes, it is not the immediate priority in this scenario. The first step in stabilizing a newborn after birth is to ensure adequate respirations and prevent heat loss.
C. Fluid balance.
Fluid balance is important in newborns, but it is not the immediate priority in this scenario. The first step in stabilizing a newborn after birth is to ensure adequate respirations and prevent heat loss.
D. Bleeding tendencies.
While newborns do have immature clotting mechanisms, making them more prone to bleeding tendencies, this is not the immediate priority in this scenario. The first step in stabilizing a newborn after birth is to ensure adequate respirations and prevent heat loss.
Full Explanation
Choice A rationale
Heat loss is a significant concern for newborns immediately after birth. Newborns have a large surface area relative to their body weight, which makes them more susceptible to heat loss.
Maintaining a warm environment is crucial to prevent hypothermia, which can lead to complications such as hypoglycemia and respiratory distress.
Choice B rationale
While hypoglycemia is a concern in newborns, especially those born to mothers with diabetes, it is not the immediate priority in this scenario. The first step in stabilizing a newborn after birth is to ensure adequate respirations and prevent heat loss.
Choice C rationale
Fluid balance is important in newborns, but it is not the immediate priority in this scenario. The first step in stabilizing a newborn after birth is to ensure adequate respirations and prevent heat loss.
Choice D rationale
While newborns do have immature clotting mechanisms, making them more prone to bleeding tendencies, this is not the immediate priority in this scenario. The first step in stabilizing a newborn after birth is to ensure adequate respirations and prevent heat loss.