Nokea
A client is in active labor and is receiving an epidural for pain relief. Which of the following should the nurse monitor as the priority?
- A. Fetal heart rate
- B. Client's blood pressure
- C. Client's respiratory rate
- D. Client's pain level
Correct Answer: B
Rationale: The most common side effect of an epidural is hypotension, which can compromise placental perfusion. Monitoring the client's blood pressure is the priority to ensure maternal and fetal well-being.
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During a breast examination on a 24-year-old client the nurse notes the following findings. Which finding is of most concern and should be reported to the provider?
- A. An irregularly shaped, nontender lump is palpable in the right breast
- B. Tenderness is present during menstruation
- C. Bilateral, symmetrical lumps that move with palpation
- D. The client reports breast tenderness before menstruation
Correct Answer: A
Rationale: An irregularly shaped, nontender lump is a concerning finding because it may indicate breast cancer. The nurse should report this finding to the provider for further investigation.
A nurse is performing a newborn assessment and notes a soft, swollen area on the newborn's scalp that does not cross the suture line. Which of the following should the nurse document?
- A. Cephalohematoma
- B. Caput succedaneum
- C. Subdural hematoma
- D. Molding
Correct Answer: A
Rationale: A cephalohematoma is a collection of blood between the periosteum and the skull that does not cross the suture line. It results from trauma during birth and typically resolves on its own.
A nurse is caring for a newborn with hyperbilirubinemia. Which of the following interventions should be taken during phototherapy?
- A. Maintain an eye mask over the newborn's eyes
- B. Feed the newborn every hour
- C. Monitor the newborn's temperature
- D. Administer vitamin K
Correct Answer: A
Rationale: Phototherapy is used to reduce bilirubin levels in newborns with jaundice. However, the intense light can cause damage to the newborn's corneas and retinas. The use of an eye mask protects the infant's eyes while allowing the therapy to proceed. Regular monitoring of the newborn's temperature and hydration status is also important, but the eye mask is a key protective measure.
A laboring client's membranes have just ruptured. What is the nurse's next action?
- A. Assess fetal heart rate pattern
- B. Monitor uterine contractions
- C. Administer oxygen
- D. Prepare for delivery
Correct Answer: A
Rationale: When a client's membranes rupture, there is a risk that the umbilical cord could become compressed, affecting blood flow to the fetus. The nurse's priority action is to assess the fetal heart rate to ensure that the fetus is not in distress.
A nurse is caring for a postmenopausal client prescribed the aromatase inhibitor, anastrozole for the treatment of breast cancer. Which of the following should the nurse tell the client she may experience?
- A. Weight gain
- B. Muscle and joint pain
- C. Night sweats
- D. Increased appetite
Correct Answer: B
Rationale: Muscle and joint pain are common side effects of aromatase inhibitors like anastrozole. These side effects can be managed with analgesics as prescribed by the healthcare provider.