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A client in labor is receiving an epidural for pain relief. What is the nurse's priority assessment immediately after the procedure?
- A. Monitor maternal blood pressure.
- B. Assess fetal heart rate.
- C. Check for bladder distention.
- D. Evaluate the client's pain level.
Correct Answer: A
Rationale: Monitoring maternal blood pressure is essential to detect and manage hypotension, a common side effect of epidurals.
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A nurse is leading a discussion about contraception with a group of 14-year-old-client. After the presentation a client asks the client which method would be best for her to use. How should the nurse respond?
- A. "Because of your age, i think that a barrier method would be the best choice."
- B. "Before i can help you, i need to know more about your sexual activity."
- C. "A provider can help you with that after a physical examination."
- D. "You are so young. Are you ready for the responsibilities of a sexual relationship?"
Correct Answer: B
Rationale: The appropriate response for the nurse to provide to the 14-year-old client who asks the best contraception method for her is to gather more information about her sexual activity first. This approach is essential in understanding the client's individual needs and situation before recommending a suitable contraceptive method. It allows the nurse to offer personalized and accurate advice based on the client's specific circumstances, rather than making assumptions or providing generic recommendations. By starting with a discussion about the client's sexual activity, the nurse can ensure that the advice given is tailored to the client's needs and preferences, promoting informed decision-making and effective contraceptive use.
A mother is learning how to breastfeed her newborn. tions, moderate variability The lactation nurse is assisting her with this process.
- A. Baseline FHR 140, occasional variable decelera- Which technique is correct? tions, moderate variability
- B. Have the mother stroke the infant's mouth with
- C. Baseline FHR 105, no accelerations, recurrent her nipple so the infant will turn toward the variable decelerations, minimal variability mother's breast for feeding.
- D. Baseline FHR 165, no decelerations, marked
Correct Answer: B
Rationale: Having the mother stroke the infant's mouth with her nipple so the infant will turn toward the mother's breast for feeding is the correct technique when assisting a mother in learning how to breastfeed her newborn. This technique helps stimulate the baby's rooting reflex, which is a natural reflex babies have to turn their head and open their mouth when their cheek is stroked.
A woman is experiencing mittelschmerz and increased vaginal discharge. Her temperature has increased by 0.6°C (1.0°F) over the past 36 hours. This most likely indicates what?
- A. Menstruation is about to begin.
- B. Ovulation will occur soon.
- C. Ovulation has occurred.
- D. She is pregnant, and will not menstruate.
Correct Answer: C
Rationale: Mittelschmerz, or mid-cycle pain, combined with a basal temperature rise and cervical mucus changes, is a sign that ovulation has occurred. These indicators are part of the body's natural fertility signals.
Which of the following medications should the nurse plan to administer?
- A. Metronidazole
- B. Penicillin
- C. Acyclovir
- D. Gentamicin
Correct Answer: A
Rationale: Among the medications listed, Metronidazole is commonly used to treat anaerobic bacterial infections, protozoal infections, and certain types of parasitic infections. It is effective against a wide range of pathogens, making it a versatile antibiotic. In this case, the nurse should plan to administer Metronidazole based on the information given in the question. Penicillin is primarily used for Gram-positive bacterial infections, Acyclovir is used for herpes virus infections, and Gentamicin is an aminoglycoside antibiotic typically used for Gram-negative bacterial infections.
In caring for an immediate postpartum client, you note she has
- A. You monitor closely for which clotting disorder? (Which bleeding problem causes this: HEELP
- C. DIC
Correct Answer: A
Rationale: In caring for an immediate postpartum client, you should monitor closely for HELLP syndrome, which stands for Hemolysis, Elevated Liver enzymes, and Low Platelet count. HELLP syndrome is a serious complication of pregnancy characterized by high blood pressure, protein in the urine, and problems with the liver and blood-clotting system. It can lead to severe bleeding issues, organ failure, and other life-threatening complications if not promptly recognized and managed. Therefore, close monitoring for signs of HELLP syndrome is crucial in the postpartum period to ensure timely intervention and prevent adverse outcomes.