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A nurse is caring for a client who is in labor and has an epidural for pain control. Which of the following clinical ... effect of epidural anesthesia?
- A. Polyuria
- B. Hypertensi on
- C. Pruritus
- D. Dry mouth
Correct Answer: C
Rationale: Epidural anesthesia can result in some common side effects, one of which is pruritus (itching). Pruritus is a known side effect of the local anesthetics used in epidural anesthesia and is due to their effects on specialized receptors in the nervous system. Patients may experience itching, especially in the face, neck, and upper chest areas. Polyuria (increased urine output), hypertension (high blood pressure), and dry mouth are not typically associated side effects of epidural anesthesia.
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The nurse is attempting to explain physiologic birth. What do they say?
- A. Physiologic birth involves interventions that do not harm the baby.â€
- B. Physiologic birth occurs only in birth centers.â€
- C. If your partner and I give you support, you can have a birth without medical intervention.â€
- D. If you want to have a cesarean birth, we can ask your health-care provider to schedule it.â€
Correct Answer: C
Rationale: Physiologic birth focuses on minimal intervention, supported by a calm environment and supportive care.
A client with chronic kidney disease has arterial blood gas values being reviewed by a nurse. Which of the following sets of values should the nurse expect?
- A. pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg
- B. pH 7.30, HCO3- 26 mEq/L, PaCO2 50 mm Hg
- C. pH 7.50, HCO3- 20 mEq/L, PaCO2 32 mm Hg
- D. pH 7.55, HCO3- 30 mEq/L, PaCO2 31 mm Hg
Correct Answer: A
Rationale: In chronic kidney disease, metabolic acidosis is common due to impaired kidney function leading to reduced bicarbonate excretion. The correct values indicating metabolic acidosis in this scenario are a low pH (acidosis), low bicarbonate (HCO3-) level, and low PaCO2 (compensation through respiratory alkalosis). Therefore, the expected values for a client with chronic kidney disease would be pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg, as depicted in choice A.
A healthcare professional is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the healthcare professional expect?
- A. HCO3- 30 mEq/L
- B. PaCO2 50 mm Hg
- C. pH 7.45
- D. Potassium 3.3 mEq/L
Correct Answer: B
Rationale: In respiratory acidosis, the primary disturbance is an increase in PaCO2 levels above the normal range of 35-45 mm Hg. Option B, PaCO2 50 mm Hg, indicates an elevated partial pressure of carbon dioxide, which is consistent with respiratory acidosis. Options A, C, and D are not directly indicative of respiratory acidosis. HCO3- (Option A) is more related to metabolic acidosis or alkalosis, pH (Option C) is within the normal range indicating no acid-base imbalance, and potassium (Option D) levels are not specific to respiratory acidosis.
The nurse is caring for a pregnant client with a diagnosis of gestational diabetes. What finding indicates the need for immediate intervention?
- A. Blood sugar of 130 mg/dL after a meal.
- B. Fasting blood sugar of 95 mg/dL.
- C. Presence of ketones in the urine.
- D. Client reports increased thirst.
Correct Answer: C
Rationale: Ketones in the urine indicate poor glucose control and possible ketoacidosis, requiring urgent medical attention.
The nurse is monitoring a client in the second stage of labor. What finding indicates the client is ready to push?
- A. Membranes have ruptured.
- B. Cervix is completely dilated.
- C. Client reports back pain.
- D. Contractions are 10 minutes apart.
Correct Answer: B
Rationale: Complete cervical dilation marks the beginning of the second stage, signaling readiness to push.