Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A. Assess the newborn's glucose level.
While it’s important to monitor a newborn’s glucose level, it’s not the immediate priority following birth.
B. Swaddle the infant and place in the bassinet.
Placing the infant in the bassinet is not the immediate priority. The newborn needs to be dried and warmed first to prevent hypothermia.
C. Dry the newborn and place it skin-to-skin on mother.
Drying the newborn and placing it skin-to-skin on the mother helps prevent hypothermia and promotes bonding. This is the immediate priority.
D. Complete a full head-to-toe assessment.
A full head-to-toe assessment is important, but it’s not the immediate priority following birth.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Custom 2023 Fall NPRO 1100 Proctored Exam 3. Take the full exam now
Full Explanation
The correct answer is choice C.
Choice A rationale:
While it’s important to monitor a newborn’s glucose level, it’s not the immediate priority following birth.
Choice B rationale:
Placing the infant in the bassinet is not the immediate priority. The newborn needs to be dried and warmed first to prevent hypothermia.
Choice C rationale:
Drying the newborn and placing it skin-to-skin on the mother helps prevent hypothermia and promotes bonding. This is the immediate priority.
Choice D rationale:
A full head-to-toe assessment is important, but it’s not the immediate priority following birth.
Similar Questions
A nurse is discussing postpartum depression with a newly licensed nurse.
Which of the following statements by the newly licensed nurse indicates an understanding of this condition?.
A. "The most common manifestation of postpartum depression is harming the infant.”. .
While some mothers with postpartum depression may have thoughts of harming their infant, it’s not the most common manifestation.
B. "Postpartum depression usually begins 48 hours after childbirth.”. .
Postpartum depression typically begins within the first few weeks after childbirth, not necessarily within 48 hours.
C. "It's common for clients who have postpartum depression to exhibit psychotic behavior.”. .
Psychotic behavior is more commonly associated with postpartum psychosis, a rare and severe form of postpartum psychiatric illness, not postpartum depression.
D. "Postpartum depression is more likely to occur in women who have a history of depression.”. .
Women with a history of depression are indeed more likely to experience postpartum depression. This is the correct answer.
Full Explanation
The correct answer is choice D.
Choice A rationale:
While some mothers with postpartum depression may have thoughts of harming their infant, it’s not the most common manifestation.
Choice B rationale:
Postpartum depression typically begins within the first few weeks after childbirth, not necessarily within 48 hours.
Choice C rationale:
Psychotic behavior is more commonly associated with postpartum psychosis, a rare and severe form of postpartum psychiatric illness, not postpartum depression.
Choice D rationale:
Women with a history of depression are indeed more likely to experience postpartum depression. This is the correct answer.
The Apgar score is based on which 5 parameters?.
A. Heart rate, respiratory effort.
Heart rate and respiratory effort are two of the five parameters of the Apgar score. However, this choice is incomplete as it does not include all five parameters.
B. Temperature, tone.
Temperature is not a parameter of the Apgar score. Tone is a parameter, but this choice is incomplete as it does not include all five parameters.
C. And color.
Color is a parameter of the Apgar score. However, this choice is incomplete as it does not include all five parameters.
D. Heart rate, breaths per minute, irritability, tone, and color.
The Apgar score is based on five parameters: heart rate, breaths per minute (respiratory effort), irritability (response to stimulation), tone (muscle tone), and color. Therefore, this choice is correct.
Full Explanation
The correct answer is choice D.
Choice A rationale:
Heart rate and respiratory effort are two of the five parameters of the Apgar score. However, this choice is incomplete as it does not include all five parameters.
Choice B rationale:
Temperature is not a parameter of the Apgar score. Tone is a parameter, but this choice is incomplete as it does not include all five parameters.
Choice C rationale:
Color is a parameter of the Apgar score. However, this choice is incomplete as it does not include all five parameters.
Choice D rationale:
The Apgar score is based on five parameters: heart rate, breaths per minute (respiratory effort), irritability (response to stimulation), tone (muscle tone), and color. Therefore, this choice is correct.
A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots 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. Notify the client's provider.
Notifying the provider is not necessary in this case as the findings are normal for a client who is 1 hour postpartum.
B. Increase the frequency of fundal massage.
Increasing the frequency of fundal massage is not necessary as the fundus is firm and at the umbilicus.
C. Document the findings and continue to monitor the client.
The findings are normal for a client who is 1 hour postpartum. The nurse should document the findings and continue to monitor the client. Therefore, this choice is correct.
D. Encourage the client to empty her bladder.
Encouraging the client to empty her bladder is not necessary in this case as the fundus is midline.
Full Explanation
The correct answer is choice C.
Choice A rationale:
Notifying the provider is not necessary in this case as the findings are normal for a client who is 1 hour postpartum.
Choice B rationale:
Increasing the frequency of fundal massage is not necessary as the fundus is firm and at the umbilicus.
Choice C rationale:
The findings are normal for a client who is 1 hour postpartum. The nurse should document the findings and continue to monitor the client. Therefore, this choice is correct.
Choice D rationale:
Encouraging the client to empty her bladder is not necessary in this case as the fundus is midline.