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A nurse is caring for a client who is hypotensive following the administration of epidural anesthesia. Which of the following actions should the nurse take?
- A. Turn the client to a side-lying position.
- B. Apply oxygen at 2 L/min via nasal cannula.
- C. Massage the client’s fundus.
- D. Assist the client to empty their bladder.
Correct Answer: A
Rationale: The correct answer is A: Turn the client to a side-lying position. This action helps improve venous return to the heart, which can increase blood pressure. Placing the client on their side can prevent compression of the vena cava by the uterus, reducing hypotension. Options B and D are not directly related to managing hypotension. Option C is incorrect as massaging the fundus is typically done postpartum to prevent hemorrhage.
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A nurse is caring for a newborn who has jaundice and a new prescription for phototherapy. Which of the following actions should the nurse take?
- A. Provide the newborn with 15 mL glucose water after each feeding.
- B. Turn the newborn every 4 hr.
- C. Apply hydrating lotion to the newborn’s skin prior to treatment.
- D. Close the newborn's eyes before applying eyepatches.
Correct Answer: D
Rationale: The correct answer is D: Close the newborn's eyes before applying eyepatches. This is important to prevent damage to the eyes from the bright light used in phototherapy. Infants' eyes are sensitive, and prolonged exposure can lead to eye damage. Option A is incorrect as glucose water is not indicated for jaundice treatment. Option B is incorrect as turning the newborn every 4 hours is not specific to phototherapy treatment. Option C is incorrect as hydrating lotion is not necessary for phototherapy. Therefore, the crucial step of closing the newborn's eyes before applying eyepatches is essential for protecting the eyes during phototherapy.
A nurse is preparing to administer metronidazole 2 g PO to a client who has trichomoniasis. Available is metronidazole 250 mg tablets. How many tablets should the nurse administer?
- A. 8 tablets
- B. 4 Tablets
- C. 2 tablets
- D. 1 tablet
Correct Answer: A
Rationale: The correct answer is A: 8 tablets. To calculate the number of tablets needed, divide the total dose (2 g) by the strength of each tablet (250 mg). 2 g is equal to 2000 mg. 2000 mg ÷ 250 mg = 8 tablets. Therefore, the nurse should administer 8 tablets of metronidazole. Choice B (4 tablets) is incorrect because it does not provide the correct dose of 2 g. Choice C (2 tablets) is incorrect as well, as it only provides half of the required dose. Choice D (1 tablet) is incorrect because it does not meet the prescribed dosage of 2 g.
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?
- A. Administer broad-spectrum antibiotics.
- B. Monitor the rectal temperature every 4 hr.
- C. Cleanse the site with povidone-iodine.
- D. Prepare for surgical closure after 72 hr.
Correct Answer: A
Rationale: The correct answer is A: Administer broad-spectrum antibiotics. This is crucial for preventing infection due to the leakage of cerebrospinal fluid, which can lead to meningitis. Antibiotics will help reduce the risk of infection until surgical repair can be done. Monitoring rectal temperature (B) is not directly related to addressing the myelomeningocele. Cleansing the site with povidone-iodine (C) may further irritate the area. Surgical closure (D) should not be delayed, as infection risk is high.
A nurse is administering a hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?
- A. Administer the injection into the vastus lateralis muscle.
- B. Vigorously massage the site following the injection.
- C. Insert the needle at a 45° angle for injection.
- D. Use a 21-gauge needle for the injection.
Correct Answer: A
Rationale: The correct answer is A: Administer the injection into the vastus lateralis muscle. For newborns, the vastus lateralis muscle is the preferred site for intramuscular injections due to its larger muscle mass and minimal nerve endings, reducing the risk of injury and increasing absorption. This site is recommended by healthcare guidelines for administering vaccines to infants to ensure proper absorption and effectiveness. The other choices are incorrect because vigorously massaging the site (B) can cause pain and tissue damage, inserting the needle at a 45° angle (C) may not reach the muscle and can cause subcutaneous injection, and using a 21-gauge needle (D) is not specific to the site and age group, potentially causing discomfort and inadequate absorption.
A nurse is planning care for a client who is 1 hr postpartum and has peripartum cardiomyopathy. Which of the following actions should the nurse plan to take?
- A. Obtain a prescription for misoprostol.
- B. Assess blood pressure twice daily.
- C. Restrict daily oral fluid intake.
- D. Administer an IV bolus of lactated Ringer's.
Correct Answer: B
Rationale: The correct answer is B: Assess blood pressure twice daily. This is crucial as peripartum cardiomyopathy can lead to heart failure and hypertension, affecting the client's blood pressure. Monitoring blood pressure twice daily allows for early detection of any changes and timely intervention. Obtaining a prescription for misoprostol (A) is not indicated as it is used for preventing gastric ulcers, not related to peripartum cardiomyopathy. Restricting oral fluid intake (C) may worsen the client's condition as adequate hydration is important for cardiac function. Administering an IV bolus of lactated Ringer's (D) could potentially worsen fluid overload and exacerbate heart failure.