Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which of the following findings should alert a nurse assessing a client who is 8 hr postpartum and multiparous?
A. Fundus three fingerbreadths above the umbilicus.
A fundus that is three fingerbreadths above the umbilicus 8 hours postpartum is a sign of urinary retention, which can displace the uterus and inhibit uterine contraction, leading to postpartum hemorrhage.
B. Moderate lochia rubra.
Moderate lochia rubra, or bloody discharge, is normal within the first few days after childbirth.
C. Blood pressure 130/84 mm Hg.
A blood pressure of 130/84 mm Hg is within the normal range for a postpartum woman.
D. Moderate swelling of the labia.
Moderate swelling of the labia can be a normal finding after a vaginal birth.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Nur 232 Maternity Final Proctored Exam Sp24. Take the full exam now
Full Explanation
Choice A rationale
A fundus that is three fingerbreadths above the umbilicus 8 hours postpartum is a sign of urinary retention, which can displace the uterus and inhibit uterine contraction, leading to postpartum hemorrhage.
Choice B rationale
Moderate lochia rubra, or bloody discharge, is normal within the first few days after childbirth.
Choice C rationale
A blood pressure of 130/84 mm Hg is within the normal range for a postpartum woman.
Choice D rationale
Moderate swelling of the labia can be a normal finding after a vaginal birth.
Similar Questions
What is the most likely cause of respiratory distress syndrome in a term macrosomic newborn whose mother has poorly controlled type 2 diabetes?
A. Increased deposits of fat in the chest and shoulder area.
Increased deposits of fat in the chest and shoulder area are not typically associated with respiratory distress syndrome in a term macrosomic newborn whose mother has poorly controlled type 2 diabetes.
B. Hyperinsulinemia.
Hyperinsulinemia is a condition in which there are excess levels of insulin circulating in the blood. In the case of a term macrosomic newborn whose mother has poorly controlled type 2 diabetes, the baby’s pancreas may produce extra insulin in response to the mother’s high blood glucose levels. This excess insulin can delay surfactant production, which is needed for lung maturation, leading to respiratory distress syndrome.
C. Brachial plexus injury.
Brachial plexus injury is a type of birth injury that can occur due to the baby’s large size and difficulty being born. However, it is not the most likely cause of respiratory distress syndrome in a term macrosomic newborn whose mother has poorly controlled type 2 diabetes.
D. Increased blood viscosity.
Increased blood viscosity can occur in newborns of mothers with poorly controlled diabetes due to polycythemia (an abnormally high number of red blood cells). However, this is not the most likely cause of respiratory distress syndrome in a term macrosomic newborn.
Full Explanation
Choice A rationale
Increased deposits of fat in the chest and shoulder area are not typically associated with respiratory distress syndrome in a term macrosomic newborn whose mother has poorly controlled type 2 diabetes.
Choice B rationale
Hyperinsulinemia is a condition in which there are excess levels of insulin circulating in the blood. In the case of a term macrosomic newborn whose mother has poorly controlled type 2 diabetes, the baby’s pancreas may produce extra insulin in response to the mother’s high blood glucose levels. This excess insulin can delay surfactant production, which is needed for lung maturation, leading to respiratory distress syndrome.
Choice C rationale
Brachial plexus injury is a type of birth injury that can occur due to the baby’s large size and difficulty being born. However, it is not the most likely cause of respiratory distress syndrome in a term macrosomic newborn whose mother has poorly controlled type 2 diabetes.
Choice D rationale
Increased blood viscosity can occur in newborns of mothers with poorly controlled diabetes due to polycythemia (an abnormally high number of red blood cells). However, this is not the most likely cause of respiratory distress syndrome in a term macrosomic newborn.
What is the purpose of placing a newborn under a radiant heat warmer after birth?
A. To prevent basal metabolic rate reduction.
Placing a newborn under a radiant heat warmer after birth does not directly prevent basal metabolic rate reduction. The primary function of a radiant heat warmer is to maintain the newborn’s body temperature and prevent hypothermia.
B. To stimulate brown fat production.
While brown fat production is a mechanism used by newborns to generate heat, placing a newborn under a radiant heat warmer does not stimulate brown fat production.
C. To maintain body temperature.
The primary purpose of placing a newborn under a radiant heat warmer after birth is to maintain the newborn’s body temperature. Newborns can lose heat rapidly, as they have a large surface area compared to their body weight. The radiant heat warmer provides a controlled environment that helps maintain the newborn’s body temperature.
D. To prevent hypothermia.
Preventing hypothermia is a key reason for placing a newborn under a radiant heat warmer. However, the direct purpose of the warmer is to maintain the newborn’s body temperature.
Full Explanation
Choice A rationale
Placing a newborn under a radiant heat warmer after birth does not directly prevent basal metabolic rate reduction. The primary function of a radiant heat warmer is to maintain the newborn’s body temperature and prevent hypothermia.
Choice B rationale
While brown fat production is a mechanism used by newborns to generate heat, placing a newborn under a radiant heat warmer does not stimulate brown fat production.
Choice C rationale
The primary purpose of placing a newborn under a radiant heat warmer after birth is to maintain the newborn’s body temperature. Newborns can lose heat rapidly, as they have a
large surface area compared to their body weight. The radiant heat warmer provides a controlled environment that helps maintain the newborn’s body temperature.
Choice D rationale
Preventing hypothermia is a key reason for placing a newborn under a radiant heat warmer. However, the direct purpose of the warmer is to maintain the newborn’s body temperature.
What action should a nurse take when 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, with the fundus midline and firm at the umbilicus?
A. Notify the client’s provider.
B. Document the findings and continue to monitor the client.
C. Increase the frequency of fundal massage.
D. Encourage the client to empty her bladder.
Full Explanation
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