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A 31-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor is receiving intravenous lactated Ringer's solution and a continuous epidural anesthetic. During the first hour after administration of the anesthetic, the nurse should monitor the client for:
- A. Hypotension.
- B. Diaphoresis.
- C. Headache.
- D. Tremors.
Correct Answer: A
Rationale: Epidural anesthesia can cause sympathetic blockade, leading to hypotension, especially within the first hour. Monitoring blood pressure is critical. Diaphoresis, headache, or tremors are less common or less urgent.
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A multigravid client admitted to the labor area is scheduled for a cesarean delivery under spinal anesthesia. After instructions by the anesthesiologist, the nurse determines that the client has understood the instructions when she says which of the following?
- A. The medication will be administered while I am in a side-lying position.'
- B. The anesthetic may cause a severe headache which is treatable.'
- C. My blood pressure may increase if I lie down too soon after the injection.'
- D. I can expect immediate anesthesia that can be reversed very easily.'
Correct Answer: B
Rationale: Spinal anesthesia carries a risk of post-dural puncture headache, which is treatable (e.g., with a blood patch). The side-lying position is for epidural, not spinal, anesthesia; blood pressure typically decreases; and spinal anesthesia is not easily reversed.
A client is considering a hormonal IUD. Which of the following benefits should the nurse highlight?
- A. It provides protection against STIs.
- B. It can reduce menstrual bleeding over time.
- C. It requires replacement every year.
- D. It is suitable for women with heavy menstrual bleeding.
Correct Answer: B
Rationale: A hormonal IUD, like Mirena, can reduce menstrual bleeding over time, often leading to lighter periods or amenorrhea. It does not protect against STIs, lasts 3-7 years depending on the type, and is suitable for heavy bleeding, but B is the primary benefit.
A multigravid client at term is admitted to the hospital for a trial labor and possible vaginal birth. She has a history of previous cesarean delivery because of fetal distress. When the client is 4 cm dilated, she receives nalbuphine (Nubain) intravenously. While monitoring the fetal heart rate, the nurse observes minimal variability and a rate of 120 bpm. The nurse should explain the decreased variability is most likely caused by which of the following?
- A. Maternal fatigue.
- B. Fetal malposition.
- C. Small-for-gestational-age fetus.
- D. Effects of analgesic medication.
Correct Answer: D
Rationale: Nalbuphine, an opioid, can reduce fetal heart rate variability by depressing the central nervous system, a common side effect. Maternal fatigue, malposition, or small-for-gestational-age fetus are less likely causes.
After teaching the parents of a neonate born with a cleft lip and cleft palate about appropriate feeding techniques, the nurse determines that the mother needs further instruction when the mother says which of the following?
- A. I should clean her mouth with soapy water after feeding.'
- B. I should feed her in an upright position.'
- C. I need to remember to burp her often.'
- D. I may need to use a special nipple for feeding.'
Correct Answer: A
Rationale: Cleaning the mouth with soapy water is inappropriate and could irritate the cleft, indicating a need for further instruction.
A client asks about the risks of the copper IUD. Which of the following would the nurse include?
- A. It may increase menstrual bleeding and cramping.
- B. It causes permanent infertility.
- C. It requires daily replacement.
- D. It increases the risk of breast cancer.
Correct Answer: A
Rationale: The copper IUD may increase menstrual bleeding and cramping, especially initially. It does not cause permanent infertility, require daily replacement, or increase breast cancer risk.