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A primigravid client who has had a prolonged labor but now is completely dilated has received epidural anesthesia. Which of the following should the nurse include in the teaching plan about pushing?
- A. The client needs to push for at least 1 to 3 minutes.
- B. Pushing is most effective when the client holds her breath.
- C. The client should be urged to push with an open glottis.
- D. Pushing is limited to times when she feels the urge.
Correct Answer: C
Rationale: Pushing with an open glottis (exhaling during effort) is effective and reduces the risk of Valsalva maneuver complications. Prolonged pushing (1–3 minutes) is unrealistic, holding breath is discouraged, and with epidurals, the urge to push may be diminished.
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While caring for a primipara diagnosed with deep vein thrombosis at 48 hours postpartum who is receiving treatment with bed rest and intravenous heparin therapy, the nurse should contact the client's physician immediately if the client exhibited which of the following?
- A. Pain in her calf.
- B. Dyspnea.
- C. Hypertension.
- D. Bradycardia.
Correct Answer: B
Rationale: Dyspnea may indicate a pulmonary embolism, a life-threatening complication requiring immediate attention.
A 28-year-old multigravida at 37 weeks' gestation arrives at the emergency department with a blood pressure of 160/104 mm Hg and +3 reflexes without clonus. The client is diagnosed with severe preeclampsia. The nurse collaborates with the health care provider to develop a plan of care that care will first include:
- A. Administration of glucocorticoids(Betamethasone).
- B. Vaginal or cesarean delivery of the fetus.
- C. Prevention of seizures with phenytoin (Dilantin).
- D. Reduction of fluid retention with thiazides.
Correct Answer: B
Rationale: Delivery is the definitive treatment for severe preeclampsia.
The nurse prepares a client for lumbar epidural anesthesia. Before anesthesia administration, the nurse instructs the client to assume which of the following positions?
- A. Sitting with back arched.
- B. Lying flat on back.
- C. Side-lying with knees bent.
- D. Prone with head elevated.
Correct Answer: A
Rationale: The sitting position with the back arched (e.g., 'shrimp' position) provides optimal access to the lumbar spine for epidural placement. Other positions do not facilitate needle insertion as effectively.
The nurse is to draw a blood sample for glucose testing from a term neonate during the first hour after birth. The nurse should obtain the blood sample from the neonate's foot near which of the following areas?
Correct Answer: B
Rationale: The blood sample should be obtained from the lateral or medial heel of the neonate's foot to minimize pain and avoid major nerves and blood vessels.
A client asks the nurse about the effectiveness of natural family planning methods. Which of the following responses by the nurse is most accurate?
- A. Natural family planning is as effective as oral contraceptives when used correctly.
- B. The effectiveness of natural family planning depends on consistent monitoring and abstinence during fertile periods.
- C. Natural family planning is less effective than barrier methods likeå®çŸ³
- D. Natural family planning requires no special equipment or cost.
Correct Answer: B
Rationale: The effectiveness of natural family planning depends on consistent monitoring and abstinence during fertile periods. It is less effective than oral contraceptives or barrier methods due to variability in ovulation and user adherence.