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During an assessment of a client in labor who received epidural anesthesia, which finding should the nurse identify as a complication of the epidural block?
- A. Vomiting
- B. Tachycardia
- C. Respiratory depression
- D. Hypotension
Correct Answer: D
Rationale: The correct answer is D: Hypotension. Epidural anesthesia can lead to hypotension due to vasodilation and sympathetic blockade, resulting in decreased blood pressure. This is a common complication that nurses should monitor for and manage promptly. Vomiting (A) is not a direct complication of epidural anesthesia. Tachycardia (B) is not typically associated with epidural anesthesia but may indicate other issues. Respiratory depression (C) is more commonly seen with opioids and not a typical complication of epidural anesthesia.
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When advising a woman considering pregnancy on nutritional needs to reduce the risk of giving birth to a newborn with a neural tube defect, what information should the nurse include?
- A. Limit alcohol consumption.
- B. Increase intake of iron-rich foods.
- C. Consume foods fortified with folic acid.
- D. Avoid foods containing aspartame.
Correct Answer: C
Rationale: The correct answer is C: Consume foods fortified with folic acid. Folic acid plays a crucial role in preventing neural tube defects in newborns. It is recommended that women of childbearing age consume 400 mcg of folic acid daily to reduce the risk. Foods fortified with folic acid include cereals, bread, and pasta.
A: Limit alcohol consumption - While important for overall health, alcohol consumption is not directly related to preventing neural tube defects.
B: Increase intake of iron-rich foods - Iron is essential during pregnancy, but it is not specifically linked to reducing the risk of neural tube defects.
D: Avoid foods containing aspartame - Aspartame is a sweetener and does not have a direct impact on neural tube defects prevention.
A woman at 38 weeks of gestation is admitted in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9°C (102°F). Besides notifying the provider, which of the following is an appropriate nursing action?
- A. Recheck the client's temperature in 4 hours.
- B. Administer glucocorticoids intramuscularly.
- C. Assess the odor of the amniotic fluid.
- D. Prepare the client for emergency cesarean section.
Correct Answer: C
Rationale: The correct answer is C: Assess the odor of the amniotic fluid. This is the appropriate nursing action because the woman is at risk for chorioamnionitis due to the elevated temperature and ruptured membranes. Assessing the odor of the amniotic fluid can help in identifying signs of infection, as foul-smelling amniotic fluid may indicate chorioamnionitis. This can guide further interventions and management, such as initiating antibiotics.
Choice A is incorrect as waiting 4 hours to recheck the temperature can delay necessary interventions for potential infection. Choice B is also incorrect as administering glucocorticoids is not the immediate priority in this situation. Choice D is incorrect as preparing for an emergency cesarean section is not warranted solely based on the client's temperature and ruptured membranes without further assessment for infection.
A client in active labor is being prepared for epidural analgesia. Which of the following actions should the nurse take?
- A. Have the client sit upright on the bed with legs crossed.
- B. Administer a 500 mL bolus of lactated Ringer's solution prior to induction.
- C. Inform the client that the anesthetic effect will last for approximately 2 hours.
- D. Obtain a 30-minute electronic fetal monitoring (EFM) strip prior to induction.
Correct Answer: D
Rationale: The correct answer is D: Obtain a 30-minute electronic fetal monitoring (EFM) strip prior to induction. This is important to assess the fetal well-being and baseline status before initiating epidural analgesia. It helps in detecting any fetal distress or abnormalities that may be exacerbated by the epidural.
A: Having the client sit upright with legs crossed is not recommended as it may interfere with the procedure and comfort of the client.
B: Administering a 500 mL bolus of lactated Ringer's solution is not directly related to preparing for epidural analgesia.
C: Informing the client about the duration of anesthetic effect is important, but ensuring fetal well-being through EFM monitoring is a priority before the procedure.
While caring for a newborn, a nurse auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take?
- A. Ask another nurse to verify the heart rate.
- B. Document this as an expected finding.
- C. Call the provider to further assess the newborn.
- D. Prepare the newborn for transport to the NICU.
Correct Answer: B
Rationale: The correct answer is B: Document this as an expected finding. A heart rate of 130/min in a newborn is within the normal range (120-160/min). The nurse should document this as an expected finding because it indicates a healthy heart rate for a newborn. There is no immediate need for intervention or further assessment as the heart rate falls within the normal range for a newborn. Asking another nurse to verify the heart rate (choice A) is unnecessary as it is within the normal range. Calling the provider to further assess the newborn (choice C) is not needed since the heart rate is normal. Preparing the newborn for transport to the NICU (choice D) is not indicated as the heart rate is within the normal range.
A client is learning how to check basal temperature to determine ovulation. When should the client check her temperature?
- A. On days 13 to 17 of her menstrual cycle
- B. Every morning before arising
- C. 1 hour following intercourse
- D. Before going to bed every night
Correct Answer: B
Rationale: The correct answer is B: Every morning before arising. This is because basal body temperature is the lowest body temperature attained during rest, typically just before waking up. Checking the temperature at this time provides the most accurate measurement of basal temperature. Options A, C, and D are incorrect because ovulation typically occurs around 14 days before the start of the next menstrual period, not on days 13 to 17 specifically (A), 1 hour following intercourse is not a reliable indicator of ovulation (C), and basal temperature should be checked in the morning, not before going to bed at night (D).