Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A. Remind her to push three times with each contraction.
While pushing is a part of labor, reminding the woman to push three times with each contraction is not the primary focus of nursing care during the transitional phase of labor.
B. Assessing the strength of uterine contractions.
Assessing the strength of uterine contractions is important, but it is not the primary focus during the transitional phase of labor.
C. Re-evaluate the need for medication.
Re-evaluating the need for medication is not the primary focus during the transitional phase of labor for a client who anticipates an unmedicated delivery.
D. Assisting her to maintain control.
Assisting the woman to maintain control is the primary focus of nursing care during the transitional phase of labor. This includes providing supportive care and encouragement in dealing with transitional contractions.
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 pushing is a part of labor, reminding the woman to push three times with each contraction is not the primary focus of nursing care during the transitional phase of labor.
Choice B rationale
Assessing the strength of uterine contractions is important, but it is not the primary focus during the transitional phase of labor.
Choice C rationale
Re-evaluating the need for medication is not the primary focus during the transitional phase of labor for a client who anticipates an unmedicated delivery.
Choice D rationale
Assisting the woman to maintain control is the primary focus of nursing care during the transitional phase of labor. This includes providing supportive care and encouragement in dealing with transitional contractions.
Similar Questions
During the newborn admission assessment, the nurse palpates the newborn’s scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?
A. Measure the size of the scrotal sac for length and width.
Measuring the size of the scrotal sac does not verify the absence of testes.
B. Observe the urethral opening on the surface of the penis when the newborn voids.
Observing the urethral opening when the newborn voids does not verify the absence of testes.
C. Use a fingertip to palpate the inguinal canal for a weakening or indentation.
If a testis is not readily identified, a finger sweep should be performed from the anterior iliac crest along the inguinal canal while palpating the scrotum. This is the correct technique to verify the absence of testes.
D. Perform transillumination of the scrotal sac to visualize shadows of the testes.
Transillumination of the scrotal sac is not the first step in verifying the absence of testes.
Full Explanation
Choice A rationale
Measuring the size of the scrotal sac does not verify the absence of testes.
Choice B rationale
Observing the urethral opening when the newborn voids does not verify the absence of testes.
Choice C rationale
If a testis is not readily identified, a finger sweep should be performed from the anterior iliac crest along the inguinal canal while palpating the scrotum. This is the correct technique to verify the absence of testes.
Choice D rationale
Transillumination of the scrotal sac is not the first step in verifying the absence of testes.
The nurse is caring for a client who is 10-weeks gestation and palpates the fundus at 2 fingerbreadths above the pubic symphysis.
The client reports nausea, vomiting, and scant dark brown vaginal discharge. Which action should the nurse take?
A. Measure vital signs.
While measuring vital signs is important, it is not the most appropriate action based on the given symptoms.
B. Obtain human chorionic gonadotropin levels.
Obtaining human chorionic gonadotropin levels is the most appropriate action. The symptoms described by the client could indicate a possible miscarriage or ectopic pregnancy, and hCG levels can help confirm this.
C. Collect urine sample for urinalysis.
Collecting a urine sample for urinalysis is not the most appropriate action based on the given symptoms.
D. Recommend bed rest.
Recommending bed rest is not the most appropriate action based on the given symptoms.
Full Explanation
Choice A rationale
While measuring vital signs is important, it is not the most appropriate action based on the given symptoms.
Choice B rationale
Obtaining human chorionic gonadotropin levels is the most appropriate action. The symptoms described by the client could indicate a possible miscarriage or ectopic pregnancy, and hCG levels can help confirm this.
Choice C rationale
Collecting a urine sample for urinalysis is not the most appropriate action based on the given symptoms.
Choice D rationale
Recommending bed rest is not the most appropriate action based on the given symptoms.
A healthcare provider prescribes a maintenance dose of 2 grams per hour of intravenous magnesium sulfate for a client with preeclampsia.
The IV bag contains 20 grams of magnesium sulfate in 500 mL of 5% dextrose in water.
How many mL/hour should the nurse set the infusion pump to deliver? (Note: This is a medical math, so no options are provided.)
Full Explanation
To calculate the rate at which the infusion pump should be set, we need to determine how many mL of the solution contain 2 grams of magnesium sulfate.
Step 1: First, we find out how many grams of magnesium sulfate are in 1 mL of the solution. The IV bag contains 20 grams of magnesium sulfate in 500 mL, so we divide 20 grams by 500 mL to get the amount of magnesium sulfate per mL: 20 grams ÷ 500 mL = 0.04 grams/mL
Step 2: Next, we find out how many mL contain 2 grams of magnesium sulfate.
We divide 2 grams by the amount of magnesium sulfate per mL: 2 grams ÷ 0.04 grams/mL = 50 mL Therefore, the nurse should set the infusion pump to deliver 50 mL per hour.