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Woman post-spinal anesthesia, pounding headache rated 7/10
A woman had spinal anesthesia for delivery. Now she complains of a pounding headache rated 7/10. What action by the nurse is most appropriate?
- A. Place a cool cloth on her forehead and dim the room lights.
- B. Prepare to assist with a blood patch procedure.
- C. Increase the rate of her nonadditive IV fluids.
- D. Give the woman IV opioid pain medications.
Correct Answer: B
Rationale: A pounding headache post-spinal anesthesia suggests a spinal headache from cerebrospinal fluid leakage, best treated with a blood patch to seal the dural puncture.
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Newborn boy, 1 minute after birth, heart rate 138 bpm, vigorous crying, spontaneous movement, pink skin with bluish hands and feet
Erin gives birth to a boy. The nurse notes the following on the baby at 1 minute: heart rate is 138 bpm, loud vigorous crying, spontaneous movement and flexion of the extremities, and pink skin color except for a bluish color of the hands and feet. What Apgar score will be assigned to the baby?
- A. 7
- B. 8
- C. 9
- D. 10
Correct Answer: B
Rationale: The baby scores 2 for heart rate (>100 bpm), 2 for respiratory effort (vigorous crying), 2 for muscle tone (spontaneous movement), 2 for reflex irritability (crying), and 1 for color (acrocyanosis), totaling an Apgar score of 8.
Client 2 hours postpartum, vaginal birth
A nurse is caring for a client who is 2 hours postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?
- A. Client report of frequent uterine contractions.
- B. Fundus palpable to right of midline.
- C. Less than 2.5 cm of rubra lochia on perineal pad.
- D. Client report of increased thirst.
Correct Answer: B
Rationale: A fundus palpable to the right of midline suggests a distended bladder, which can displace the uterus from its normal position.
Newborns in nursery
A nurse receives handoff report. Which newborn should the nurse assess first?
- A. Glucose reading 58 mg/dL.
- B. Pulse 144 beats/minute.
- C. Respiratory rate 78 breaths/minute.
- D. Temperature 97.7° F (36.5° C).
Correct Answer: C
Rationale: A respiratory rate of 78 breaths/minute indicates tachypnea, suggesting potential respiratory distress, which requires immediate assessment.
Client at 40 weeks gestation, active labor, 6 cm cervical dilation, 100% effacement, blood pressure 82/52 mm Hg
A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?
- A. Assist the client to turn onto her side.
- B. Prepare for an immediate vaginal delivery.
- C. Prepare for a cesarean birth.
- D. Assist the client to an upright position.
Correct Answer: A
Rationale: Assisting the client to turn onto her side can improve blood flow to the placenta and increase fetal oxygenation, addressing hypotension which is a common cause of decreased uteroplacental perfusion.
Vacuum extraction birth
While assisting with a vacuum extraction birth, what should the nurse immediately report to the physician?
- A. Maternal pulse rate of 100 bpm.
- B. Maternal blood pressure of 120/70 mm Hg.
- C. Decrease in intensity of uterine contractions.
- D. Persistent fetal bradycardia below 100 bpm.
Correct Answer: D
Rationale: Persistent fetal bradycardia below 100 bpm indicates potential fetal distress, requiring immediate reporting to ensure fetal safety.