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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 promotes venous return to the heart and helps increase blood pressure. When a client is hypotensive, changing their position can prevent further decrease in blood pressure and maintain perfusion to vital organs. Applying oxygen (B) may be helpful, but addressing the positioning is the priority. Massaging the fundus (C) is not indicated for hypotension related to epidural anesthesia. Assisting the client to empty their bladder (D) may be necessary for comfort but does not directly address the hypotension.
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A nurse is caring for a client who is receiving an epidural block with an opioid analgesic. The nurse should monitor for which of the following findings as an adverse effect of the medication?
- A. Hyperglycemia
- B. Bilateral crackles
- C. Hypotension
- D. Polyuria
Correct Answer: C
Rationale: Correct Answer: C (Hypotension)
Rationale: Opioid analgesics can cause vasodilation leading to hypotension. The epidural route can potentiate this effect due to direct spinal cord vasodilation. Monitoring for hypotension is crucial to prevent adverse outcomes such as decreased perfusion.
Incorrect Choices:
A: Hyperglycemia - Opioid analgesics typically do not cause hyperglycemia.
B: Bilateral crackles - Crackles are indicative of fluid accumulation in the lungs, not a typical adverse effect of opioid analgesics.
D: Polyuria - Opioid analgesics do not commonly cause increased urine output.
A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception. Which of the following instructions should the nurse include?
- A. You should have your provider refit you for a new diaphragm.'
- B. You should use an oil-based vaginal lubricant when inserting your diaphragm.'
- C. You should keep the diaphragm in place for at least 4 hours after intercourse.'
- D. You should store your diaphragm in sterile water after each use.'
Correct Answer: A
Rationale: Correct Answer: A. The nurse should instruct the client to have her provider refit her for a new diaphragm because the body undergoes changes postpartum, affecting the size and shape of the cervix and vaginal canal. A new fitting ensures proper size and fit for effective contraception.
B: Using oil-based vaginal lubricant can damage the diaphragm and increase the risk of breakage.
C: Keeping the diaphragm in place for a prolonged period increases the risk of toxic shock syndrome and infection, so it should be removed within 24 hours.
D: Storing the diaphragm in sterile water can lead to bacterial growth, increasing the risk of infection. It should be stored in a dry, cool place.
A nurse is assessing a client who is 1 hr postpartum following a vaginal birth. The nurse notes that the client has excessive vaginal bleeding. Which of the following actions should the nurse take first?
- A. Massage the client's fundus.
- B. Administer oxytocin to the client.
- C. Empty the client’s bladder.
- D. Provide oxygen to the client via nonrebreather face mask.
Correct Answer: A
Rationale: The correct action for the nurse to take first is to massage the client's fundus. This is because excessive vaginal bleeding postpartum could indicate uterine atony, which is a common cause of postpartum hemorrhage. By massaging the fundus, the nurse can help stimulate uterine contractions and reduce bleeding. Administering oxytocin (choice B) may be necessary but massaging the fundus should be done first. Emptying the client's bladder (choice C) can also help, but addressing uterine atony is the priority. Providing oxygen (choice D) is not the immediate action needed for excessive vaginal bleeding.
A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take?
- A. Limit the amount of time the fetus is in the client’s room.
- B. Provide the client with photos of the fetus.
- C. Instruct the client that an autopsy should be performed within 24 hr.
- D. Inform the client that the law requires them to name the fetus.
Correct Answer: B
Rationale: The correct answer is B: Provide the client with photos of the fetus. This action allows the client to have tangible memories of their stillborn child, which can aid in the grieving process and provide closure. Providing photos is a sensitive and compassionate gesture that acknowledges the significance of the loss. It also respects the client's autonomy in choosing how they wish to remember their child.
The other choices are not appropriate in this situation:
A: Limiting the time the fetus is in the room may not consider the emotional needs of the client.
C: Instructing the client about an autopsy may be insensitive and distressing without discussing it first with the client.
D: Informing the client about naming the fetus is not a legal requirement and could add unnecessary pressure during a difficult time.
A nurse is teaching about car seat safety to the parents of a newborn who was delivered at 38 weeks of gestation. Which of the following statements by a parent indicates an understanding of the teaching?
- A. I can use a sleep sack to keep my baby warm in the car seat.'
- B. My baby will need a car seat challenge test before discharge.'
- C. The car seat should be positioned in the car at a 45-degree angle.'
- D. When my baby is 1 year old, I can turn their car seat facing forward.'
Correct Answer: C
Rationale: Correct Answer: C - The car seat should be positioned in the car at a 45-degree angle.
Rationale: Placing the car seat at a 45-degree angle helps protect a newborn's airway and prevents slumping, ensuring optimal safety during travel. This position aligns the baby's head with the neck and spine, reducing the risk of suffocation and injury in the event of sudden stops or accidents. A 45-degree angle also supports proper breathing and oxygenation for the newborn. Therefore, this statement indicates the parent understands the importance of correctly positioning the car seat for their baby's safety.
Summary of Incorrect Choices:
A: Incorrect - Using a sleep sack in the car seat can lead to overheating and compromise the baby's safety by interfering with the car seat's harness system.
B: Incorrect - A car seat challenge test is typically done for premature infants, not a newborn delivered at 38 weeks of gestation.
D: Incorrect - Turning a baby's car seat forward-facing