Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
When preforming an initial assessment on a full-term infant whose parents are Asian, the nurse notes a blue-gray discoloration across the sacrum of the newborn. What is the most appropriate action for the nurse to take?
A. Review clotting studies lab report
Clotting studies are unnecessary as Mongolian spots are not related to a bleeding disorder.
B. Document the findings in the electronic health record
Mongolian spots are a normal finding in newborns with increased melanin deposition in the skin. The nurse should document the finding to differentiate it from potential bruising in future assessments.
C. Report parents to Child Protective Services
Reporting parents to Child Protective Services is inappropriate because Mongolian spots are congenital, not signs of abuse.
D. Notify the healthcare provider
Notifying the healthcare provider is unnecessary as Mongolian spots are a normal variation, not a medical concern.
This question is an excerpt from Nurse Dive's nursing test bank - Ati nur209 pediatrics final assessment proctored exam 2025. Take the full exam now
Full Explanation
A. Clotting studies are unnecessary as Mongolian spots are not related to a bleeding disorder.
B. Mongolian spots are a normal finding in newborns with increased melanin deposition in the skin. The nurse should document the finding to differentiate it from potential bruising in future assessments.
C. Reporting parents to Child Protective Services is inappropriate because Mongolian spots are congenital, not signs of abuse.
D. Notifying the healthcare provider is unnecessary as Mongolian spots are a normal variation, not a medical concern.
Similar Questions
A nurse is discharging a child who has sickle cell anemia after an acute crisis episode. Which of the following instructions should the nurse include in the teaching?
A. "Restrict outdoor play activity to 1 hour per day."
There is no need to overly restrict activity; appropriate exercise is encouraged.
B. "Offer fluids to your child multiple times every day."
Adequate hydration helps decrease blood viscosity and reduces the risk of vaso-occlusive crises in children with sickle cell anemia.
C. "Apply cold compresses when your child expresses pain."
Cold compresses may worsen vaso-occlusion; warm compresses are generally preferred.
D. "Monitor your child's temperature daily."
While monitoring for fever is important, ensuring proper hydration is a key measure to help prevent future crises.
Full Explanation
A. There is no need to overly restrict activity; appropriate exercise is encouraged.
B. Adequate hydration helps decrease blood viscosity and reduces the risk of vaso-occlusive crises in children with sickle cell anemia.
C. Cold compresses may worsen vaso-occlusion; warm compresses are generally preferred.
D. While monitoring for fever is important, ensuring proper hydration is a key measure to help prevent future crises.
The nurse educates the parents on actions to prevent sudden infant death syndrome. Which observation indicates the teaching has been effective?
A. Newborn is placed in bassinet with blanket draped over them
Over-bundling or draping blankets over the infant increases the risk of suffocation.
B. Newborn is placed in bassinet on the back
Placing the newborn on its back to sleep is the recommended practice to reduce the risk of SIDS.
C. The newborn is on an every 2-hour feeding schedule
While regular feeding schedules are important, they do not directly address SIDS prevention.
D. Mother removes pacifier from the newborns mouth
Use of a pacifier has been associated with a reduced risk of SIDS, not its removal.
Full Explanation
A. Over-bundling or draping blankets over the infant increases the risk of suffocation.
B. Placing the newborn on its back to sleep is the recommended practice to reduce the risk of SIDS.
C. While regular feeding schedules are important, they do not directly address SIDS prevention.
D. Use of a pacifier has been associated with a reduced risk of SIDS, not its removal.
Which nursing interventions are appropriate while caring for a newborn whose mother was addicted to heroin during the pregnancy? (Select All that Apply.)
A. Observe the newborn in a well-lit nursery
A well-lit nursery is not recommended; a dim, quiet environment is preferred to reduce stimulation.
B. Feed the infant half strength formula
Feeding half-strength formula is not a standard intervention for infants experiencing withdrawal; feeding should follow the infant's needs and standard nutritional guidelines.
C. Swaddle newborn with legs flexed
Swaddle newborn with legs flexed – Proper swaddling helps comfort the infant and can reduce withdrawal symptoms.
D. Maintain low stimulation environment
Maintain low stimulation environment – Minimizing noise and bright lights helps decrease overstimulation and agitation common in neonatal abstinence syndrome.
E. Offer the newborn a pacifier
Offer the newborn a pacifier – A pacifier can be soothing and help manage irritability.
F. Administer oral glucose for comfort
Administer oral glucose for comfort – Oral glucose (or sucrose) is a nonpharmacological intervention that can help alleviate pain and provide comfort.
Full Explanation
A. A well-lit nursery is not recommended; a dim, quiet environment is preferred to reduce stimulation.
B. Feeding half-strength formula is not a standard intervention for infants experiencing withdrawal; feeding should follow the infant's needs and standard nutritional guidelines.
C. Swaddle newborn with legs flexed – Proper swaddling helps comfort the infant and can reduce withdrawal symptoms.
D. Maintain low stimulation environment – Minimizing noise and bright lights helps decrease overstimulation and agitation common in neonatal abstinence syndrome.
E. Offer the newborn a pacifier – A pacifier can be soothing and help manage irritability.
F. Administer oral glucose for comfort – Oral glucose (or sucrose) is a nonpharmacological intervention that can help alleviate pain and provide comfort.