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A nurse is caring for a client who has received an epidural during labor. Which of the following actions should the nurse take?
- A. Position a wedge under the clients left hip
- B. Place the client in the lithotomy position
- C. Assist the client to a knee chest position
- D. Elevate the head of the client’s bed to 90%
Correct Answer: A
Rationale: The correct answer is A: Position a wedge under the client's left hip. Placing a wedge under the left hip helps to optimize the distribution of the epidural medication, ensuring even pain relief. This positioning can also help prevent uneven spread of the medication, reducing the risk of complications such as uneven numbness or motor weakness.
Choice B: Placing the client in the lithotomy position is incorrect because this position is not recommended for clients with epidurals as it may increase the risk of hypotension.
Choice C: Assisting the client to a knee-chest position is incorrect because this position is not suitable for clients with epidurals and may cause discomfort or compromise the effectiveness of the epidural.
Choice D: Elevating the head of the client's bed to 90% is incorrect as it is not directly related to optimizing the effects of the epidural.
In summary, positioning a wedge under the client's left hip is the most appropriate action to ensure optimal distribution and effectiveness
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A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?
- A. Transient circumoral cyanosis
- B. Single palmar creases
- C. Subconjunctival hemorrhage
- D. Rust-stained urine
Correct Answer: B
Rationale: The correct answer is B: Single palmar creases. This finding may indicate the presence of Down syndrome or other genetic disorders. The presence of single palmar creases warrants further evaluation by the provider to rule out any underlying conditions. Transient circumoral cyanosis, subconjunctival hemorrhage, and rust-stained urine are common and typically benign findings in newborns that do not require immediate reporting.
A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Provide a stimulating environment
- B. Monitor blood glucose level every hr.
- C. Initiate seizure precautions.
- D. Place the infants on his back with legs extended.
Correct Answer: B
Rationale: The correct answer is B: Monitor blood glucose level every hr. Neonatal abstinence syndrome can lead to hypoglycemia in infants. Monitoring blood glucose levels every hour allows for early detection and intervention. Providing a stimulating environment (A) can worsen symptoms. Initiating seizure precautions (C) is not necessary unless seizures are present. Placing the infant on his back with legs extended (D) does not address the specific issue of neonatal abstinence syndrome.
A nurse is caring for a client who is receiving oxytocin to induce labor. The nurse should discontinue the oxytocin if which of the following occurs?
- A. Contractions last 60 seconds
- B. Non-repetitive early decelerations
- C. 6 contractions in 10 minutes
- D. Moderate variability of the fetal heart rate
Correct Answer: A
Rationale: The correct answer is A: Contractions last 60 seconds. Prolonged contractions can lead to uterine hyperstimulation, which can decrease oxygen supply to the fetus, posing a risk of fetal distress. Discontinuing oxytocin in this situation is crucial to prevent further complications.
B: Non-repetitive early decelerations are not directly related to oxytocin administration and do not warrant discontinuation of the medication.
C: 6 contractions in 10 minutes is a sign of uterine hyperstimulation but alone may not be enough to discontinue oxytocin.
D: Moderate variability of the fetal heart rate is a reassuring sign of fetal well-being, not an indication to discontinue oxytocin.
A nurse is assessing a newborn immediately following a vaginal birth. For which of the following findings should the nurse intervene?
- A. Molding
- B. Vernix Caseosa
- C. Acrocyanosis
- D. Sternal retractions
Correct Answer: D
Rationale: The correct answer is D: Sternal retractions. Sternal retractions in a newborn indicate respiratory distress, potentially due to a blocked airway or difficulty breathing. The nurse should intervene immediately to ensure the newborn's airway is clear and that they are able to breathe properly.
A: Molding is the overlapping of cranial bones during birth, a common and temporary finding.
B: Vernix Caseosa is a protective coating on the newborn's skin and is normal.
C: Acrocyanosis is the bluish discoloration of the hands and feet, a common finding in newborns due to immature circulation.
A nurse is caring for a client who has a complete uterine rupture. Which of the following findings should the nurse expect?
- A. Early fetal heart rate decelerations
- B. Hypotension
- C. Painless, dark red vaginal bleeding
- D. bounding peripheral pulses
Correct Answer: B
Rationale: The correct answer is B: Hypotension. A complete uterine rupture is a serious complication where the uterine wall tears completely, leading to massive internal bleeding. This can result in hypotension due to blood loss. Early fetal heart rate decelerations (choice A) are not indicative of uterine rupture. Painless, dark red vaginal bleeding (choice C) is more commonly associated with placental abruption. Bounding peripheral pulses (choice D) are not a typical finding in uterine rupture.