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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 prevent aortocaval compression, a potential cause of hypotension after epidural anesthesia. When the client is lying on their back, the weight of the uterus can compress the vena cava, reducing venous return and cardiac output, leading to hypotension. Turning the client to a side-lying position relieves this compression, improving blood flow and helping to stabilize blood pressure.
Summary:
B: Applying oxygen may be beneficial in some cases, but it does not directly address the underlying cause of hypotension in this scenario.
C: Massaging the fundus is not indicated for hypotension following epidural anesthesia.
D: Assisting the client to empty their bladder may be important for overall comfort and prevention of complications, but it does not address the hypotension directly.
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A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make?
- A. "The nurse will carry your baby in their arms to the nursery for scheduled procedures."
- B. "We will document the relationship of visitors in your medical record."
- C. "It's okay for your baby to sleep in the bed with you while in the hospital."
- D. "Staff members who take care of your baby will be wearing a photo identification badge."
Correct Answer: D
Rationale: The correct answer is D: "Staff members who take care of your baby will be wearing a photo identification badge." This statement promotes security and safety by ensuring that only authorized personnel are handling the newborn. It helps prevent unauthorized individuals from accessing the baby. The photo identification badge serves as visual confirmation of the staff members' credentials and authority. This measure enhances the client's peace of mind and trust in the healthcare team.
Other choices are incorrect:
A: Carrying the baby to the nursery for procedures may not guarantee security as it could expose the baby to unnecessary risks.
B: Documenting visitor relationships is important but does not directly address the safety and security of the newborn.
C: Sharing a bed with the baby can increase the risk of accidental suffocation or other sleep-related risks.
Overall, choice D is the most direct and effective way to ensure the security and safety of the newborn.
Which of the following conditions should the nurse identify as being consistent with the adolescent's assessment findings? For each finding click to specify if the assessment findings are consistent with trichomoniasis, gonorrhea, or candidiasis. Each finding may support more than one disease process.
- A. Abdominal pain.
- B. Greenish discharge.
- C. Diabetes.
- D. Pain on urination.
- E. Absence of condom.
Correct Answer: B, D
Rationale: Sure, here is the detailed explanation:
- Trichomoniasis: Trichomoniasis typically presents with greenish discharge but not pain on urination.
- Gonorrhea: Gonorrhea can cause both greenish discharge and pain on urination.
- Candidiasis: Candidiasis does not typically present with greenish discharge or pain on urination.
Therefore, based on the assessment findings provided:
- Abdominal pain: Not specific to any of the given conditions.
- Greenish discharge: Consistent with both gonorrhea and trichomoniasis.
- Diabetes: Not directly related to the symptoms provided.
- Pain on urination: Consistent with gonorrhea.
- Absence of condom: Not relevant to the symptoms provided.
The correct answer is B, D as greenish discharge and pain on urination are consistent with both gonorrhea and trichomoniasis, making them the most likely conditions based on the assessment findings.
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. Single palmar creases (p200
- B. Down Syndrome)
- C. Rust-stained urine
- D. Transient circumoral cyanosis
- E. Subconjunctival hemorrhage
Correct Answer: A
Rationale: The correct answer is A: Single palmar creases. This finding is associated with Down Syndrome, which requires further evaluation by the provider. Single palmar creases are a physical characteristic commonly seen in infants with Down Syndrome. Reporting this to the provider allows for early intervention and appropriate management. Choices B, C, D, and E are incorrect because Down Syndrome (choice B) is not a clinical finding to report but rather a condition associated with single palmar creases. Rust-stained urine (choice C) may indicate hematuria but is not a common concern in newborns. Transient circumoral cyanosis (choice D) is a common finding in newborns that usually resolves on its own. Subconjunctival hemorrhage (choice E) is also a common and benign finding in newborns.
A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?
- A. Blood pressure 105/64 mm Hg
- B. Heart rate 98/min
- C. Urine output of 280 mL within 8 hr
- D. Urine negative for ketones
Correct Answer: D
Rationale: The correct answer is D: Urine negative for ketones. In hyperemesis gravidarum, excessive vomiting can lead to dehydration and ketosis. A negative urine ketone result indicates the client may not be adequately hydrated or receiving proper nutrition. This finding should be reported to the provider for further evaluation and intervention. Option A (Blood pressure 105/64 mm Hg) is within normal range for a pregnant woman. Option B (Heart rate 98/min) is slightly elevated but may be due to dehydration. Option C (Urine output of 280 mL within 8 hr) is inadequate and indicates poor fluid intake or excessive fluid loss. Reporting a negative urine ketone result is crucial to prevent further complications.
The nurse is teaching the client about postpartum depression. The nurse should encourage the client to----------------- and ----------------- to help prevent postpartum depression.
- A. Engage in regular physical activity
- B. Maintain a strong support system
- C. Get adequate rest and sleep
- D. Eat a well-balanced diet
- E. exercise 30 min per day
Correct Answer: B,E
Rationale: The correct answers are B and E. Maintaining a strong support system is crucial for emotional well-being, as it provides the client with reassurance, understanding, and help in times of need. This can help prevent feelings of isolation and loneliness, common in postpartum depression. Additionally, exercising for at least 30 minutes per day can release endorphins, improve mood, and reduce stress, all of which can contribute to preventing postpartum depression. Choices A, C, and D are important for overall health but do not specifically address the emotional and mental aspects that can lead to postpartum depression.