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A nurse is reviewing the prescriptions for a client who is pregnant and is taking digoxin. Which of the following actions should the nurse take to best evaluate the client’s medication adherence?
- A. Ask the client if they are taking the medication as prescribed.
- B. Assess the client’s kidney function.
- C. Determine the client’s apical pulse rate.
- D. Check the client’s serum medication level.
Correct Answer: D
Rationale: The correct answer is D: Check the client's serum medication level. This is the best way to evaluate medication adherence for digoxin. Digoxin has a narrow therapeutic range, so monitoring the serum level ensures the client is taking the correct dose. Choices A, B, and C do not directly assess medication adherence for digoxin. Asking the client may not reflect the actual medication intake, kidney function assessment is important but not for adherence evaluation, and apical pulse rate may be affected by various factors. Checking the serum level provides objective data on the drug concentration in the body, indicating adherence.
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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 due to decreased systemic vascular resistance. The nurse should monitor the client for signs of hypotension such as lightheadedness, dizziness, and decreased blood pressure. Monitoring for hypotension is crucial to prevent complications like decreased perfusion to vital organs.
Summary:
A: Hyperglycemia - Opioid analgesics do not typically cause hyperglycemia.
B: Bilateral crackles - This finding is more indicative of fluid overload or heart failure, not a direct effect of opioid analgesics.
D: Polyuria - Opioid analgesics do not usually cause polyuria; in fact, they can cause urinary retention as a side effect due to bladder sphincter relaxation.
A nurse is caring for a newborn immediately following birth. For which of the following reasons should the nurse delay the instillation of antibiotic ophthalmic ointment?
- A. To allow manifestations of infection to be identified
- B. The newborn weighs less than 2.5 kg (5.5 lb)
- C. The newborn was delivered via cesarean birth
- D. To facilitate bonding between the newborn and parent
Correct Answer: D
Rationale: Rationale: The correct answer is D - To facilitate bonding between the newborn and parent. Instillation of antibiotic ointment can interfere with the bonding process between the newborn and parent, as it may create a barrier between them. Bonding is crucial for establishing a strong emotional connection and attachment between the newborn and parent, which is important for the newborn's overall well-being. Delaying the instillation allows for uninterrupted skin-to-skin contact and bonding. Choices A, B, and C are incorrect because delaying antibiotic ointment instillation does not affect the identification of infection manifestations, the newborn's weight, or the mode of delivery.
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?
- A. Hematuria
- B. Proteinuria 2+
- C. Leukorrhea
- D. Positive clonus
- E. BUN 40 mg/dL
- F. Platelet count 110,000/mm3
Correct Answer:
Rationale: Correct Answer:
Rationale: The correct interpretation is Hematuria. Hematuria (blood in urine) can be a sign of potential worsening condition, requiring further investigation. Proteinuria 2+, Leukorrhea, Positive clonus, BUN of 40 mg/dL, and Platelet count of 110,000/mm3 are not specifically related to the findings 24 hours later and do not provide direct information on the client's status. Hematuria should be a significant focus for further assessment.
A nurse is assessing a newborn following a forceps-assisted birth. Which of the following clinical manifestations should the nurse identify as a complication of this birth method?
- A. Polycythemia
- B. Hypoglycemia
- C. Bronchopulmonary dysplasia
- D. Facial palsy
Correct Answer: D
Rationale: The correct answer is D: Facial palsy. Forceps-assisted birth can put pressure on the baby's face, potentially leading to facial nerve injury and resulting in facial palsy. This occurs due to the compression of the facial nerve during delivery. Other choices are incorrect: A - Polycythemia is not directly related to forceps-assisted birth. B - Hypoglycemia is more commonly associated with maternal diabetes or prematurity. C - Bronchopulmonary dysplasia is a lung condition primarily seen in premature infants requiring mechanical ventilation or oxygen therapy. In summary, facial palsy is the most likely complication following a forceps-assisted birth due to the pressure exerted on the baby's face during delivery.
A nurse is assessing a client who is 3 days postpartum. Which of the following findings should the nurse report to the provider?
- A. Cool, clammy skin
- B. Moderate lochia serosa
- C. Heart rate 89/min
- D. BP 120/70 mm Hg
Correct Answer: A
Rationale: The correct answer is A: Cool, clammy skin. This finding could indicate hypovolemia or shock, which are serious postpartum complications. The nurse should report this to the provider immediately for further evaluation and intervention.
Other choices are not as urgent:
B: Moderate lochia serosa is expected 3 days postpartum.
C: Heart rate of 89/min is within normal range for a postpartum client.
D: BP of 120/70 mm Hg is also within normal limits.
Therefore, the nurse should prioritize reporting the cool, clammy skin over the other findings.