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Client in labor with an epidural for pain control.
A nurse is caring for a client who is in labor and has an epidural for pain control. Which of the following clinical manifestations is an adverse effect of epidural anesthesia?
- A. Polyuria.
- B. Hypertension.
- C. Pruritus.
- D. Dry mouth.
Correct Answer: C
Rationale: Pruritus is a frequent side effect of epidural anesthesia, particularly when using opioids like fentanyl, due to histamine release or opioid receptors activation in the spinal cord.
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Client gave birth 4 hr ago and is experiencing excessive vaginal bleeding.
A nurse is caring for a client who gave birth 4 hr ago and is experiencing excessive vaginal bleeding. Which of the following actions should the nurse plan to take first?
- A. Elevate the client's legs to a 30° angle.
- B. Insert an indwelling urinary catheter.
- C. Massage the client's fundus.
- D. Initiate an infusion of oxytocin.
Correct Answer: C
Rationale: Massaging the fundus promotes uterine contraction, which is the first-line intervention to control postpartum hemorrhage caused by uterine atony.
Client gave birth 12 hours ago and is experiencing excessive vaginal bleeding.
A nurse is assessing a client who gave birth 12 hours ago and is experiencing excessive vaginal bleeding. Which of the following findings indicates the client is experiencing decreased cardiac output?
- A. Bradycardia.
- B. Flushed face.
- C. Hypotension.
- D. Polyuria.
Correct Answer: C
Rationale: Hypotension, defined as blood pressure below 90/60 mmHg, occurs due to reduced blood volume and cardiac output in excessive postpartum bleeding, impairing adequate perfusion to organs and tissues.
Client at 31 weeks of gestation receiving magnesium sulfate via continuous IV infusion for preterm labor.
A nurse is assessing a client who is at 31 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion for preterm labor. Which of the following findings should the nurse report to the provider?
- A. Respiratory rate 11/min.
- B. Deep tendon reflexes 2+.
- C. Urine output 30 mL/hr.
- D. Blood pressure 100/62 mm Hg.
Correct Answer: A
Rationale: A respiratory rate of 11/min is below the normal adult range of 12–20/min and indicates respiratory depression, a potential adverse effect of magnesium sulfate requiring immediate intervention.
Four postpartum clients: 1 day ago needs Rh(D) immune globulin, 3 days ago reports breast fullness, 12 hours ago reports increased urinary output, 8 hours ago saturating a perineal pad every hour.
A nurse on a postpartum unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?
- A. A client who gave birth 1 day ago and needs Rh(D) immune globulin.
- B. A client who gave birth 3 days ago and reports breast fullness.
- C. A client who gave birth 12 hours ago and reports an increase in urinary output.
- D. A client who gave birth 8 hours ago and is saturating a perineal pad every hour.
Correct Answer: D
Rationale: Saturating a perineal pad every hour 8 hours postpartum indicates heavy vaginal bleeding, potentially signifying postpartum hemorrhage, a life-threatening condition requiring immediate evaluation and intervention.
Client who is breastfeeding and has mastitis.
A nurse is planning care for a client who is breastfeeding and has mastitis. Which of the following interventions should the nurse include?
- A. Instruct the client to wash their hands prior to breastfeeding.
- B. Teach the client about proper latching-on techniques.
- C. Encourage the client to alternate breastfeeding with formula feeding.
- D. Encourage the client to allow their nipples to air dry after feedings.
Correct Answer: A,B,D
Rationale: Handwashing (A) minimizes pathogen transmission. Proper latching techniques (B) reduce nipple trauma and facilitate milk drainage. Allowing nipples to air dry (D) promotes healing and reduces infection risk.