Nokea
A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first?
- A. Raise the foot of the bed
- B. Assess for vaginal bleeding
- C. Evaluate the fetal heart rate
- D. Take the client's blood pressure
Correct Answer: A
Rationale: These symptoms are suggestive of hypotension which is a side effect of epidural anesthesia. Raising the foot of the bed (A) will increase venous return and provide blood to the vital areas. Increasing the IV fluid rate using a balanced non-dextrose solution and ensuring that the silent is in a lateral position are also appropriate interventions.
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Which patient would require additional calories and nutrients?
- A. A 36-year-old female gravida 2, para 1, in her first trimester of pregnancy
- B. An 18-year-old female who delivered a 7-lb baby and is bottle feeding
- C. A 23-year-old female who had a cesarean birth and is bottle feeding
- D. A 20-year-old female who had a vaginal birth 5 months ago and is breastfeeding
Correct Answer: D
Rationale: The correct answer is D because breastfeeding requires additional calories and nutrients to support the mother's milk production and maintain her own health. Breastfeeding burns extra calories, so the mother needs to consume more to meet her body's needs. Additionally, breastfeeding mothers need to ensure they are getting enough nutrients like calcium, iron, and protein to support their own health and the production of nutritious breast milk for their baby.
Choice A is incorrect because the patient is in her first trimester of pregnancy, not breastfeeding. Choice B is incorrect because bottle feeding does not require as many additional calories and nutrients as breastfeeding. Choice C is incorrect because although the patient had a cesarean birth, the method of feeding (bottle feeding) does not require as much additional nutrition as breastfeeding.
The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception?
- A. Between the time the temperature falls and rises
- B. Between 36 and 48 hours after the temperature rises
- C. When the temperature falls and remains low for 36 hours
- D. Within 72 hours before the temperature falls
Correct Answer: A
Rationale: In most women, the BBT drops slightly 24 to 36 hours before ovulation and rises 24 to 72 hours after ovulation, when the corpus luteum of the ruptured ovary produces progesterone. Therefore, intercourse between the time of the temperature fall and rise (A) is the best time for conception.
When assessing a pregnant woman AT 39-weeks gestation who is admitted to labor and delivery which finding is most important to report to the health care provider?
- A. proteinuria
- B. 130/70 blood pressure
- C. pedal edema
- D. 101.2 oral temperature
Correct Answer: D
Rationale: Fever (D) can indicate infection, which requires prompt evaluation.
A patient at 8 weeks' gestation complains to the nurse, 'I feel sick almost every morning. And I throw up at least two or three times a week.' What is the nurse's best guidance for this patient?
- A. Do you like cheese?'
- B. Try eating four meals a day instead of three meals a day.'
- C. Try eating peanut butter on whole wheat bread right before going to bed.'
- D. If you can eat enough throughout the day, you don't have to worry about being sick.'
Correct Answer: C
Rationale: The correct answer is C: 'Try eating peanut butter on whole wheat bread right before going to bed.' This recommendation is based on the fact that consuming a small snack high in protein and complex carbohydrates before going to bed can help stabilize blood sugar levels and reduce morning sickness symptoms in pregnant women. Peanut butter provides protein and whole wheat bread provides complex carbohydrates, which can help alleviate nausea and vomiting.
Choice A is incorrect because asking about cheese does not address the patient's symptoms or provide any practical guidance for managing morning sickness.
Choice B is incorrect because increasing the number of meals may not necessarily alleviate morning sickness and could potentially exacerbate symptoms.
Choice D is incorrect because suggesting that eating enough throughout the day will prevent sickness oversimplifies the issue and does not offer targeted advice for managing morning sickness.
A diabetic client delivers a full-term large for gestation-age (LGA) infant who is jittery. What action should the nurse take first?
- A. Administer oxygen
- B. Feed the infant glucose water (10%)
- C. Obtain a blood glucose level
- D. Decrease environment stimuli
Correct Answer: C
Rationale: Jitteriness in LGA infants suggests hypoglycemia, so obtaining a blood glucose level (C) is the priority.