Nokea
At 0600, while admitting a woman for a scheduled repeat cesarean section (C-section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?
- A. Start prescribed IV with lactated Ringer's.
- B. Inform the anesthesia care provider.
- C. Ensure preoperative lab results are available.
- D. Contact the client's obstetrician.
Correct Answer: B
Rationale: Caffeine intake may alter anesthesia effects, and the anesthesiologist needs to be informed first to manage potential complications like increased gastric acidity and delayed gastric emptying.
You may also like to solve these questions
The client has experienced an eclamptic seizure. Which of the following interventions by the nurse will help stabilize the client? (Select all that apply)
- A. Explaining procedures.
- B. Treating nausea.
- C. Ensuring side rails are padded.
- D. Assisting with breast pumping.
- E. Evaluating blood pressure frequently.
- F. Evaluating for headache.
- G. Assessing deep tendon reflexes.
Correct Answer: C,E,G,H
Rationale: Padded side rails, frequent blood pressure checks, reflex assessment, and minimizing visitors stabilize the client by preventing injury, monitoring hypertension, and reducing seizure triggers.
After two miscarriages, a client is instructed to increase her daily intake of foods that includes folic acid. The client does not like green leafy vegetables and states she is allergic to soy. Which food should the nurse suggest that the client eat to obtain folic acid?
- A. Yogurt.
- B. Whole milk.
- C. Collard greens.
- D. Strawberries.
Correct Answer: D
Rationale: Strawberries are a good source of folic acid, suitable for the client's dietary restrictions, unlike yogurt, milk, or collard greens, which either lack folic acid or are disliked.
The nurse is performing a newborn assessment. Which symptom, if present in a newborn, would indicate respiratory distress?
- A. Shallow and irregular respirations.
- B. Flaring of the nares.
- C. Abdominal breathing with synchronous chest movement.
- D. Respiratory rate of 50 breaths per minute.
Correct Answer: B
Rationale: Nasal flaring indicates increased breathing effort, a sign of respiratory distress in newborns, unlike normal respiratory patterns.
A client who is positive for Neisseria gonorrhoeae vaginally delivered a newborn. Which medication should the nurse administer to the newborn?
- A. Erythromycin ointment.
- B. Neomycin ointment.
- C. Tetracaine eye drops.
- D. Latanoprost eye drops.
Correct Answer: A
Rationale: Erythromycin ointment is the standard prophylaxis for ophthalmia neonatorum caused by Neisseria gonorrhoeae, preventing severe eye infections.
A woman who is trying to get pregnant tells the nurse that she was very disappointed several months ago when she was informed that her positive pregnancy test was a false positive. Which method of determining pregnancy provides the greatest degree of accuracy?
- A. Visualization of implantation by vaginal ultrasound.
- B. Maternal blood serum tests positive for alpha-fetoprotein.
- C. Presence of amenorrhea for 2 months.
- D. Reports feeling tired all of the time.
Correct Answer: A
Rationale: Vaginal ultrasound directly visualizes the implanted embryo, providing the highest accuracy compared to biochemical tests or subjective symptoms, which can be misleading.