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A nurse is caring for a client who is in labor and has an epidural for pain control. Which of the following clinical ... effect of epidural anesthesia?
- A. Polyuria
- B. Hypertensi on
- C. Pruritus
- D. Dry mouth
Correct Answer: C
Rationale: Epidural anesthesia can result in some common side effects, one of which is pruritus (itching). Pruritus is a known side effect of the local anesthetics used in epidural anesthesia and is due to their effects on specialized receptors in the nervous system. Patients may experience itching, especially in the face, neck, and upper chest areas. Polyuria (increased urine output), hypertension (high blood pressure), and dry mouth are not typically associated side effects of epidural anesthesia.
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The nurse is monitoring a client with severe preeclampsia. What assessment finding indicates worsening condition?
- A. Proteinuria of +1.
- B. Respiratory rate of 16 breaths per minute.
- C. New-onset confusion and restlessness.
- D. Urine output of 40 mL/hr.
Correct Answer: C
Rationale: New-onset confusion and restlessness may indicate cerebral edema or impending eclampsia.
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: C
Rationale: Neonatal abstinence syndrome (NAS) occurs in infants who are exposed to addictive substances in utero, typically opioids. The signs of NAS can include irritability, tremors, feeding difficulties, and seizures. Therefore, it is essential for the nurse to initiate seizure precautions when caring for an infant with signs of NAS. This includes ensuring a safe environment, padding the crib, monitoring closely for seizure activity, and having emergency medications readily available if needed. Providing a stimulative environment (Option A) would be inappropriate as it can exacerbate symptoms of NAS. While monitoring blood glucose (Option B) is important in some situations, such as for infants of diabetic mothers, it is not the priority in NAS. Placing the infant on their back with legs extended (Option D) does not directly address the immediate concerns related to NAS.
Which data in the patient's history should the nurse recognize as being pertinent to a possible diagnosis of postpartum depression?
- A. Previous depressive episode
- B. Unexpected operative birth
- C. Ambivalence during the first trimester
- D. Second pregnancy in a 3-year period
Correct Answer: A
Rationale: A previous history of depression is a significant risk factor for postpartum depression. Women who have experienced a depressive episode in the past are more likely to develop postpartum depression compared to those without such a history. Recognizing this pertinent data in the patient's history can help the nurse identify individuals at higher risk for postpartum depression and provide appropriate support and intervention. The other options mentioned (B. Unexpected operative birth, C. Ambivalence during the first trimester, D. Second pregnancy in a 3-year period) may also contribute to emotional distress but are not as directly linked to postpartum depression as a previous depressive episode.
The nurse is teaching a prenatal class about breast changes during pregnancy. Which change is expected?
- A. Decrease in nipple pigmentation.
- B. Reduction in breast size.
- C. Darkening of the areola.
- D. Development of inverted nipples.
Correct Answer: C
Rationale: Darkening of the areola is a common change due to hormonal influences during pregnancy.
When reviewing the arterial blood gas values for a client, a nurse notes a pH of 7.32, PaCO2 of 48 mm Hg, and HCO3 of 23 mEq/L. What does this indicate about the acid-base balance?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: A
Rationale: The given values suggest respiratory acidosis. In respiratory acidosis, the pH is low (<7.35), PaCO2 is high (>45 mm Hg), and the HCO3 is normal or slightly elevated. In this scenario, the low pH (7.32) and high PaCO2 (48 mm Hg) indicate respiratory acidosis, where there is an excess of carbon dioxide in the blood, leading to acidification of the body fluids.