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A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?
- A. Place the client in a supine position for 30 min following the first dose of anesthetic solution.
- B. Administer 1,000 mL of dextrose 5% in water prior to the first dose of anesthetic solution.
- C. Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution.
- D. Ensure the client has been NPO 4 hr prior to the placement of the epidural and the first dose of anesthetic solution.
Correct Answer: C
Rationale: Correct Answer: C. Monitor the client's blood pressure every 5 minutes following the first dose of anesthetic solution.
Rationale: Continuous monitoring of the client's blood pressure is crucial after administering epidural anesthesia to detect any potential hypotension, a common side effect. By monitoring every 5 minutes, the nurse can promptly intervene if hypotension occurs, preventing maternal and fetal compromise.
Summary of other choices:
A: Placing the client in a supine position can lead to hypotension due to inferior vena cava compression. Incorrect.
B: Administering dextrose solution is unrelated to epidural anesthesia and not indicated for pain control. Incorrect.
D: NPO status is not directly related to epidural anesthesia administration. Incorrect.
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The nurse is reviewing the provider's prescriptions in the adolescent's medical chart.Complete the following sentence by using the list of options. The nurse should first implement ---------------------- and ---------------------------------
- A. Providing education on medications
- B. Administering ceftriaxone
- C. Administering metronidazole and educating on condom use
Correct Answer: A,B
Rationale: The correct answer is A,B. First, providing education on medications is crucial to ensure the adolescent understands the prescribed treatment. This empowers them to adhere to the regimen, promoting better health outcomes. Second, administering ceftriaxone aligns with the provider's prescription and is a direct action the nurse must take to carry out the treatment plan. Choices C, D, E, F, and G are incorrect because administering metronidazole and educating on condom use (C) is not the immediate priority. Administering metronidazole is not mentioned in the provider's prescriptions, so it is not the first step. Choices D, E, F, and G are irrelevant and not related to the provider's prescriptions or the adolescent's care.
A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?
- A. Decreased heart rate.
- B. Chin quivering.
- C. Pinpoint pupils.
- D. Slowed respirations.
Correct Answer: B
Rationale: The correct answer is B: Chin quivering. Pain assessment in newborns can be challenging due to their limited ability to communicate. Chin quivering is a nonverbal sign of pain in newborns. It indicates stress and discomfort. Decreased heart rate, pinpoint pupils, and slowed respirations are not reliable indicators of pain in newborns and may be attributed to other factors. Therefore, the nurse should identify chin quivering as a significant sign of pain in this scenario.
For each assessment finding, click to specify if the finding is consistent with hypoglycemia, hyperbilirubinemia, or sepsis.
- A. Ecchymotic caput Succedaneum.
- B. Decreased temperature.
- C. Lethargy.
- D. Poor feeding.
- E. Respiratory distress.
- F. Yellow sclera and oral mucosa.
Correct Answer: B, C, D, E, F
Rationale: The correct answer is . Decreased temperature (B) can indicate hypoglycemia, sepsis, or hypothermia. Lethargy (C) can be a sign of hypoglycemia, sepsis, or other serious conditions. Poor feeding (D) is common in hypoglycemia, sepsis, and other illnesses. Respiratory distress (E) is a red flag for sepsis. Yellow sclera and oral mucosa (F) suggest hyperbilirubinemia. Ecchymotic caput Succedaneum (A) is not typically associated with these conditions.
A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication?
- A. Increased fetal movement.
- B. Leakage of fluid from the vagina.
- C. Upper abdominal discomfort.
- D. Urinary frequency.
Correct Answer: B
Rationale: The correct answer is B: Leakage of fluid from the vagina. Following an amniocentesis, leakage of fluid from the vagina can indicate a potential complication such as amniotic fluid leakage, which can lead to preterm labor or infection. This finding should be reported to the provider promptly for further evaluation and management. Increased fetal movement (choice A) is a normal occurrence and not typically indicative of a complication. Upper abdominal discomfort (choice C) and urinary frequency (choice D) are common side effects post-amniocentesis and usually resolve without intervention.
A nurse is providing teaching to the parents of a newborn about newborn genetic screening. Which of the following statements should the nurse Include in the teaching?
- A. This test will be repeated when your baby is 2 months old.
- B. A nurse will draw blood from your baby's inner elbow.
- C. This test should be performed after your baby is 24 hours old.
- D. Your baby will be given 2 ounces of water to drink prior to the test.
Correct Answer: C
Rationale: Rationale: The correct answer is C because newborn genetic screening should be performed after the baby is 24 hours old to ensure accurate results. Testing too early may lead to false negatives. Choice A is incorrect because the test is typically done once soon after birth. Choice B is incorrect as blood is usually drawn from the baby's heel, not inner elbow. Choice D is incorrect as newborns should not be given water before the test due to risk of aspiration.