Nokea
After being in labor several hours with no progress the patient diagnosed with CPD and must have a c/s. the patient is worried that she will not be able to have any future children vaginally. After sharing this info with her care provider, the nurse would anticipate should would receive what type of incision?
- A. Transverse
- B. Vertical
- C. Low vertical
- D. Pfannenstiel
Correct Answer: B
Rationale: The correct answer is B: Vertical incision. In cases of CPD (cephalopelvic disproportion) where labor is not progressing and a cesarean section is necessary, a vertical incision is typically performed. This type of incision allows for better access to the uterus and is preferred in emergency situations like CPD. A transverse incision (choice A) is commonly used in elective c-sections but may not provide enough access in cases of CPD. Low vertical (choice C) is not ideal for CPD as it limits visibility and access. Pfannenstiel incision (choice D) is a horizontal incision placed low on the abdomen and is typically used in elective c-sections, not specifically for CPD cases.
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A nurse is reinforcing teaching about reducing perineal infection with a client following a vaginal delivery. Which of the following should the nurse include in the teaching? (Select all that apply.)
- A. Blot the perineal area dry after cleansing.
- B. Clean the perineal area from front to back.
- C. Perform hand hygiene before and after voiding.
- D. Wash the perineal area using a squeeze bottle of warm water after each voiding.
Correct Answer: A
Rationale: Correct Answer: A - Blot the perineal area dry after cleansing.
Rationale: Blotting the perineal area dry after cleansing helps prevent moisture accumulation, reducing the risk of perineal infection. Moisture can create a favorable environment for bacterial growth and infection. This practice also helps maintain skin integrity and promotes healing post-vaginal delivery.
Summary of other choices:
B: Cleaning the perineal area from front to back is important to prevent introducing fecal bacteria to the urinary tract but is not directly related to reducing perineal infection.
C: Performing hand hygiene before and after voiding is crucial for infection prevention but does not directly address reducing perineal infection.
D: Washing the perineal area using a squeeze bottle of warm water after each voiding can be beneficial for cleanliness but does not specifically address reducing perineal infection like blotting dry after cleansing does.
A nurse is planning care for a client who is receiving oxytocin by continuous IV infusion for labor induction. Which of the following interventions should the nurse include in the plan?
- A. Increase the infusion rate every 30 to 60 min.
- B. Maintain the client in a supine position.
- C. Titrate the infusion rate by 4 milliunits/min.
- D. Limit IV intake to 4 L per 24 hr.
Correct Answer: C
Rationale: The correct answer is C: Titrate the infusion rate by 4 milliunits/min. This is the appropriate intervention because oxytocin is a potent uterotonic agent used for labor induction. By titrating the infusion rate by 4 milliunits/min, the nurse can closely monitor and adjust the dose to achieve the desired uterine contractions without causing hyperstimulation. Increasing the infusion rate every 30 to 60 min (A) can lead to rapid and uncontrolled contractions. Maintaining the client in a supine position (B) can decrease blood flow to the placenta. Limiting IV intake to 4 L per 24 hr (D) is not necessary and may lead to dehydration.
A nurse is caring for a client who is receiving Iv magnesium sulfate which of the following medication should the nurse anticipate administering if magnesium sulfate toxicity is suspected?
- A. Nifedipine (Adalat)
- B. Pyridoxine (vitamin B)
- C. Ferrous sulfate
- D. Calcium gluconate
Correct Answer: D
Rationale: The correct answer is D: Calcium gluconate. In cases of magnesium sulfate toxicity, calcium gluconate is administered as an antidote due to its ability to counteract the effects of magnesium. Magnesium and calcium ions have an antagonistic relationship in the body, so administering calcium gluconate can help reverse the toxic effects of magnesium. Nifedipine (A), Pyridoxine (B), and Ferrous sulfate (C) do not have a direct antidote effect on magnesium toxicity and are not indicated for this purpose.
The nurse is monitoring a postpartum client. What finding requires immediate action?
- A. Fundus firm and midline.
- B. Lochia rubra with large clots.
- C. Mild perineal discomfort.
- D. Slight swelling of the feet.
Correct Answer: B
Rationale: The correct answer is B because Lochia rubra with large clots may indicate excessive bleeding or a possible postpartum hemorrhage, which requires immediate intervention to prevent complications. A: Fundus firm and midline is a normal finding postpartum. C: Mild perineal discomfort is expected after childbirth. D: Slight swelling of the feet is common due to fluid shifts and does not require immediate action.
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. Hypnosis
- B. Polyuria
- C. Bilateral crackles
- D. Hyperglycemia
Correct Answer: C
Rationale: The correct answer is C: Bilateral crackles. When a client is receiving an opioid analgesic via an epidural block, a potential adverse effect is respiratory depression, leading to the accumulation of fluid in the lungs and the development of bilateral crackles upon auscultation. Hypnosis (choice A) is not typically associated with opioid analgesics. Polyuria (choice B) is not a common side effect of opioids or epidural blocks. Hyperglycemia (choice D) is not a direct adverse effect of opioid analgesics administered through an epidural block. Monitoring for bilateral crackles is crucial to detect and address respiratory depression promptly.