Nokea
A client reports unrelieved episiotomy pain 8 hours following a vaginal birth. Which of the following actions should the nurse take?
- A. Apply an ice pack to the affected area.
- B. Offer a warm sitz bath.
- C. Provide a squeeze bottle of antiseptic solution.
- D. Place a hot pack on the perineum.
Correct Answer: A
Rationale: The correct answer is A: Apply an ice pack to the affected area. Ice helps reduce inflammation and numb the pain, providing relief for the client. Step 1: Ice constricts blood vessels, reducing swelling and pain. Step 2: Ice numbs the area, providing immediate relief. Step 3: Ice is recommended for acute pain management. Summary: B (warm sitz bath) may increase blood flow and exacerbate swelling. C (antiseptic solution) is not indicated for pain relief. D (hot pack) may worsen inflammation and pain.
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During an assessment of a client in labor who received epidural anesthesia, which finding should the nurse identify as a complication of the epidural block?
- A. Vomiting
- B. Tachycardia
- C. Respiratory depression
- D. Hypotension
Correct Answer: D
Rationale: The correct answer is D: Hypotension. Epidural anesthesia can lead to hypotension due to vasodilation and sympathetic blockade, resulting in decreased blood pressure. This is a common complication that nurses should monitor for and manage promptly. Vomiting (A) is not a direct complication of epidural anesthesia. Tachycardia (B) is not typically associated with epidural anesthesia but may indicate other issues. Respiratory depression (C) is more commonly seen with opioids and not a typical complication of epidural anesthesia.
A client in active labor is being prepared for epidural analgesia. Which of the following actions should the nurse take?
- A. Have the client sit upright on the bed with legs crossed.
- B. Administer a 500 mL bolus of lactated Ringer's solution prior to induction.
- C. Inform the client that the anesthetic effect will last for approximately 2 hours.
- D. Obtain a 30-minute electronic fetal monitoring (EFM) strip prior to induction.
Correct Answer: D
Rationale: The correct answer is D: Obtain a 30-minute electronic fetal monitoring (EFM) strip prior to induction. This is important to assess the fetal well-being and baseline status before initiating epidural analgesia. It helps in detecting any fetal distress or abnormalities that may be exacerbated by the epidural.
A: Having the client sit upright with legs crossed is not recommended as it may interfere with the procedure and comfort of the client.
B: Administering a 500 mL bolus of lactated Ringer's solution is not directly related to preparing for epidural analgesia.
C: Informing the client about the duration of anesthetic effect is important, but ensuring fetal well-being through EFM monitoring is a priority before the procedure.
A patient on the labor and delivery unit is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 minutes, last 90 seconds, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. Which of the following actions should the nurse take?
- A. Decrease the rate of infusion of the maintenance IV solution.
- B. Discontinue the infusion of the IV oxytocin.
- C. Increase the rate of infusion of the IV oxytocin.
- D. Slow the client's breathing rate.
Correct Answer: B
Rationale: The correct answer is B: Discontinue the infusion of the IV oxytocin. Decelerations starting at the peak of contractions indicate uteroplacental insufficiency, which can be caused by hyperstimulation from oxytocin. Stopping the oxytocin infusion will help alleviate this issue and improve fetal oxygenation. Choice A would not address the underlying cause of the decelerations. Choice C would worsen the hyperstimulation. Choice D is not directly related to the fetal heart rate decelerations.
A parent of a newborn is being taught about crib safety. Which statement by the client indicates understanding of the teaching?
- A. I will place my baby on his stomach when he is sleeping.
- B. I should remove extra blankets from my baby's crib.
- C. I should pad the mattress in my baby's crib so that he will be more comfortable when he sleeps.
- D. I should place my baby's crib next to the heater to keep him warm during the winter.
Correct Answer: B
Rationale: The correct answer is B because removing extra blankets from the baby's crib reduces the risk of suffocation and Sudden Infant Death Syndrome (SIDS). Placing the baby on the stomach (Option A) increases the risk of SIDS. Padding the mattress (Option C) can also increase the risk of suffocation. Placing the crib next to a heater (Option D) can lead to overheating and poses a fire hazard. Removing extra blankets ensures a safe sleep environment for the baby.
A healthcare professional is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the healthcare professional's priority?
- A. Respiratory distress
- B. Hypothermia
- C. Accidental lacerations
- D. Acrocyanosis
Correct Answer: A
Rationale: The correct answer is A: Respiratory distress. This is the priority assessment because a newborn's ability to breathe is crucial for survival. Immediate evaluation of respiratory status is essential to ensure the baby is receiving adequate oxygenation. Hypothermia (choice B) can be addressed after addressing any respiratory issues. Accidental lacerations (choice C) are important but not as immediately life-threatening as respiratory distress. Acrocyanosis (choice D) is a common finding in newborns and does not require immediate intervention unless associated with other concerning symptoms.