Nokea
A client who received an epidural for her operative delivery has vomited twice since the surgery. Which of the following prn medications ordered by the anesthesiologist should the nurse administer at this time?
- A. Reglan (metoclopramide).
- B. Demerol (meperidine).
- C. Seconal (secobarbital).
- D. Benadryl (diphenhydramine).
Correct Answer: A
Rationale: Reglan treats nausea.
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Research has shown that with lesbian parents, the non-birthing person can feel role resentment, exclusion from health-care services, and feelings of neglect. How can the nurse include the non-birthing partner?
- A. Ask the person to leave the room during the newborn assessment.
- B. Educate the person to leave the feeding up to the birthing person.
- C. Demonstrate newborn care to both parents.
- D. Ask the person’s family how they feel about their relationship.
Correct Answer: C
Rationale: The correct answer is C: Demonstrate newborn care to both parents. This option promotes inclusivity and involvement of both parents in caring for the newborn, addressing feelings of neglect and exclusion. It allows the non-birthing partner to actively participate in the care process, fostering bonding and reducing role resentment.
A: Asking the person to leave the room during the newborn assessment isolates and excludes them, exacerbating feelings of neglect.
B: Educating the person to leave feeding to the birthing person further marginalizes them and does not address their emotional needs.
D: Asking the person's family about their relationship does not directly involve the non-birthing partner and does not address their feelings of exclusion.
The nurse is providing care to a patient 2 hours after a cesarean birth. In the hand-off report, he preceding nurse indicated that the patient’s lochia was scant rubra. On initial assessment, the oncoming nurse notes the patient’s peripad is saturated with lochia rubra immediately after breastfeeding her infant. What is the nurse’s priority action with this finding?
- A. Weigh the peripad.
- B. Replace the peripad.
- C. Contact the health care provider.
- D. Document the finding in the patient’s chart.
Correct Answer: C
Rationale: The correct answer is C: Contact the health care provider. This is the priority action because the sudden increase in lochia flow after breastfeeding could indicate postpartum hemorrhage, which is a serious complication that requires immediate medical attention. Contacting the healthcare provider will allow for prompt assessment and intervention.
A: Weigh the peripad - This is not the priority action as assessing the amount of blood loss is important, but contacting the healthcare provider for further assessment and intervention takes precedence.
B: Replace the peripad - While maintaining cleanliness and hygiene is important, addressing the potential postpartum hemorrhage is the priority.
D: Document the finding in the patient’s chart - Documentation is necessary but should come after the immediate concern of postpartum hemorrhage is addressed.
A mother is told that she should bottle feed her child for medical reasons. Which of the following maternal disease states are consistent with the recommendation? Select all that apply.
- A. Untreated
- B. active tuberculosis.
- C. Hepatitis B surface antigen positive.
- D. Human immunodeficiency virus positive.
Correct Answer: A
Rationale: Breastfeeding is contraindicated in untreated TB and HIV.
The nurse is assessing a newborn on admission to the newborn nursery. Which of the following findings should the nurse report to the neonatologist?
- A. Intracostal retractions.
- B. Caput succedaneum.
- C. Epstein's pearls.
- D. Harlequin sign.
Correct Answer: A
Rationale: Intracostal retractions indicate respiratory distress and require immediate attention.
A client's vital signs and reflexes were normal throughout pregnancy, labor, and delivery. Four hours after delivery the client's vitals are 98.6°F, P 72, R 20, BP 150/100, and her reflexes are 4+. She has an intravenous infusion running with 20 units of Pitocin (oxytocin) added. Which of the following actions by the nurse is appropriate?
- A. Nothing, because the results are normal.
- B. Notify the obstetrician of the findings.
- C. Discontinue the intravenous immediately.
- D. Reassess the client after fifteen minutes.
Correct Answer: B
Rationale: Elevated blood pressure requires medical evaluation.