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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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What nutrient is particularly important for individuals during preconception to reduce the risk of neural tube defects in their fetus?
- A. iron
- B. calcium
- C. folate
- D. vitamin C
Correct Answer: C
Rationale:
The nurse is monitoring a client in labor who is receiving oxytocin. What finding requires immediate intervention?
- A. Contractions lasting 90 seconds.
- B. Contractions every 2–3 minutes.
- C. Fetal heart rate of 100 beats/minute.
- D. Maternal heart rate of 85 beats/minute.
Correct Answer: C
Rationale: A fetal heart rate of 100 bpm indicates bradycardia, which may signify fetal distress and requires immediate action.
A nurse is caring for a client who is in the first stage of labor and is using pattern-paced breathing. The client says she feels lightheaded and her fingers are tingling. Which of the following actions should the nurse take?
- A. Administer oxygen via nasal cannula.
- B. Assist the client to breathe into a paper bag.
- C. Have the client tuck her chin to her chest.
- D. Instruct the client to increase her respiratory rate to more than 42 breaths per min.
Correct Answer: A
Rationale: The client is exhibiting signs of hyperventilation, which can occur as a result of rapid breathing techniques such as pattern-paced breathing during labor. Administering oxygen via nasal cannula can help the client rebalance her oxygen and carbon dioxide levels, which will alleviate the lightheadedness and tingling sensations she is experiencing. Oxygen therapy is the appropriate intervention for respiratory alkalosis caused by hyperventilation. Assisting the client to breathe into a paper bag or instructing her to increase her respiratory rate would exacerbate the hyperventilation and should be avoided. Tucking her chin to her chest is not an appropriate intervention in this situation.
A client at 35 weeks' gestation reports mild vaginal bleeding and no pain. What condition should the nurse suspect?
- A. Abruptio placentae.
- B. Placenta previa.
- C. Preterm labor.
- D. Urinary tract infection.
Correct Answer: B
Rationale: Painless vaginal bleeding in late pregnancy is a classic sign of placenta previa.
A healthcare professional is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the healthcare professional expect?
- A. HCO3- 30 mEq/L
- B. PaCO2 50 mm Hg
- C. pH 7.45
- D. Potassium 3.3 mEq/L
Correct Answer: B
Rationale: In respiratory acidosis, the primary disturbance is an increase in PaCO2 levels above the normal range of 35-45 mm Hg. Option B, PaCO2 50 mm Hg, indicates an elevated partial pressure of carbon dioxide, which is consistent with respiratory acidosis. Options A, C, and D are not directly indicative of respiratory acidosis. HCO3- (Option A) is more related to metabolic acidosis or alkalosis, pH (Option C) is within the normal range indicating no acid-base imbalance, and potassium (Option D) levels are not specific to respiratory acidosis.