Nokea
A client in labor requests epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?
- A. Position the client supine for 30 minutes after the first dose of anesthetic solution.
- B. Administer 1,000 mL of dextrose 5% in water after the first dose of anesthetic solution.
- C. Monitor the client's blood pressure every 5 minutes after the first dose of anesthetic solution.
- D. Ensure the client has been NPO for 4 hours before the placement of the epidural and the first dose of anesthetic solution.
Correct Answer: C
Rationale: The correct answer is C: Monitor the client's blood pressure every 5 minutes after the first dose of anesthetic solution. This is crucial as epidural anesthesia can cause hypotension, which can lead to maternal and fetal complications. Monitoring blood pressure every 5 minutes allows for early detection and intervention.
A: Positioning the client supine for 30 minutes after the first dose of anesthetic solution can lead to hypotension due to decreased venous return, so this is incorrect.
B: Administering dextrose 5% in water is not a standard practice after epidural anesthesia and does not address the risk of hypotension, so this is incorrect.
D: Ensuring the client has been NPO for 4 hours before the procedure is important for general anesthesia but not specifically for epidural anesthesia, so this is incorrect.
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A client in a family planning clinic requests oral contraceptives. Which of the following findings in the client's history should be recognized as contraindications to oral contraceptives? (Select all that apply.)
- A. Cholecystitis
- B. Hypertension
- C. Migraine headaches
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. Cholecystitis, hypertension, and migraine headaches are all contraindications to oral contraceptives. Cholecystitis can be exacerbated by oral contraceptives. Hypertension increases the risk of cardiovascular events with oral contraceptives. Migraine headaches, especially with aura, are associated with an increased risk of stroke when combined with oral contraceptives. Therefore, considering these risks, it is crucial to recognize these findings as contraindications to prescribing oral contraceptives.
A healthcare professional is assisting with the care for a client who is experiencing a ruptured ectopic pregnancy. Which of the following findings is expected with this condition?
- A. No alteration in menses
- B. Transvaginal ultrasound indicating a fetus in the uterus
- C. Blood progesterone greater than the expected reference range
- D. Report of severe shoulder pain
Correct Answer: D
Rationale: The correct answer is D: Report of severe shoulder pain. In a ruptured ectopic pregnancy, the fertilized egg implants outside the uterus, usually in the fallopian tube. As the tube ruptures, there is internal bleeding which can irritate the diaphragm, causing referred pain to the shoulder. This phenomenon is known as Kehr's sign. The other choices are incorrect because with a ruptured ectopic pregnancy, there would typically be altered menses due to the pregnancy disruption, a transvaginal ultrasound would not show a fetus in the uterus, and blood progesterone levels would not be elevated.
A charge nurse on the postpartum unit is observing a newly licensed nurse who is preparing to administer pain medication to a client. The charge nurse should intervene when the newly licensed nurse uses which of the following secondary identifiers to identify the client?
- A. The client's room number
- B. The client's telephone number
- C. The client's birth date
- D. The client's medical record number
Correct Answer: A
Rationale: The correct answer is A: The client's room number. Using the client's room number as a secondary identifier is not appropriate as it does not uniquely identify the client and can lead to errors. The room number may change, or there could be multiple clients in the same room. Telephone number, birth date, and medical record number are more reliable secondary identifiers as they are unique to the client and less likely to be confused with another individual. It is essential to use accurate and reliable identifiers to ensure patient safety and prevent medication errors.
When caring for a client suspected of having hyperemesis gravidarum, which finding is a manifestation of this condition?
- A. Hgb 12.2 g/dL
- B. Urine ketones present
- C. Alanine aminotransferase 20 IU/L
- D. Blood glucose 114 mg/dL
Correct Answer: B
Rationale: The correct answer is B: Urine ketones present. Hyperemesis gravidarum is a severe form of nausea and vomiting during pregnancy, leading to dehydration and ketonuria. Presence of urine ketones indicates fat breakdown due to inadequate calorie intake. Option A is within normal range for hemoglobin. Option C is within normal range for alanine aminotransferase. Option D is within normal range for blood glucose. Thus, the presence of urine ketones is the most indicative finding for hyperemesis gravidarum.
A nurse at an antepartum clinic is caring for a client who is at 4 months of gestation. The client reports continued nausea, vomiting, and scant, prune-colored discharge. The client has experienced no weight loss and has a fundal height larger than expected. Which of the following complications should the nurse suspect?
- A. Hyperemesis gravidarum
- B. Threatened abortion
- C. Hydatidiform mole
- D. Preterm labor
Correct Answer: C
Rationale: The correct answer is C: Hydatidiform mole. At 4 months of gestation, prune-colored discharge indicates possible passage of vesicular tissue characteristic of a molar pregnancy. This, along with continued nausea, vomiting, and larger fundal height, are signs of a hydatidiform mole. Hyperemesis gravidarum (A) typically involves severe nausea and vomiting leading to weight loss, which the client did not experience. Threatened abortion (B) presents with vaginal bleeding and cramping, not prune-colored discharge. Preterm labor (D) is characterized by regular contractions leading to cervical changes, not the symptoms described.