Nokea
Following a cesarean birth, intrathecal morphine is administered to the patient for postoperative pain management. Of which fact about intrathecal morphine therapy is the nurse aware? Select all that apply.
- A. An anesthesiologist or CRNA administers it intrathecally.
- B. The nurse needs to closely monitor for common side effects.
- C. The drug produces generalized CNS depression.
- D. The recommended dose is 10 to 15 mg.
Correct Answer: B
Rationale: The correct answer is B: The nurse needs to closely monitor for common side effects.
1. Intrathecal morphine can lead to side effects such as respiratory depression, nausea, vomiting, and pruritus.
2. Monitoring for these side effects is crucial for early detection and intervention.
3. Anesthesiologists or CRNAs typically administer intrathecal morphine, not nurses.
4. Intrathecal morphine primarily acts locally at the spinal cord level, not producing generalized CNS depression.
5. The recommended dose of intrathecal morphine is typically much lower than 10-15 mg to avoid overdose and side effects.
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When assessing a prenatal client at follow-up prenatal visits during the second trimester, the nurse should anticipate which assessments to be performed at each visit? Select all that apply.
- A. Cervical examination
- B. Weight, height, BMI
- C. Fetal ultrasound
- D. Fundal height
Correct Answer: B
Rationale: The correct answer is B: Weight, height, BMI. During each second-trimester prenatal visit, it is essential to monitor the client's weight, height, and BMI to ensure appropriate maternal and fetal health. Weight gain is a crucial indicator of fetal growth and maternal well-being. Height and BMI can provide insights into the client's nutritional status and overall health.
Explanation of why other choices are incorrect:
A: Cervical examination is typically not performed routinely during second-trimester prenatal visits unless there are specific concerns such as preterm labor risk.
C: Fetal ultrasound is usually scheduled at specific times during pregnancy, not necessarily at every second-trimester visit.
D: Fundal height measurement is important, but it is usually performed starting in the second trimester to assess fetal growth and position, not necessarily at every visit.
A patient who is expecting her first baby tells the nurse, “I am afraid of the whole birth experience and plan to ask the doctor for a cesarean delivery.” Which response by the nurse is most appropriate?
- A. I will get you some material about how labor pain is managed.
- B. Most women avoid cesarean births unless it is an emergency.
- C. I suggest you talk with the physician and get another opinion.
- D. Cesarean will cause you issues with additional pregnancies.
Correct Answer: B
Rationale: The correct answer is B: Most women avoid cesarean births unless it is an emergency.
Rationale:
1. Cesarean delivery is a major surgery with potential risks and longer recovery time compared to vaginal birth.
2. Most women opt for vaginal birth unless there are medical reasons necessitating a cesarean section.
3. It is important for the nurse to educate the patient on the benefits of vaginal birth and address her fears about the birth experience.
4. Encouraging the patient to consider vaginal birth unless there is a medical emergency aligns with best practices in obstetric care.
Summary:
- Choice A is incorrect because focusing solely on pain management may not address the patient's underlying fear of the birth experience.
- Choice C is incorrect as seeking another opinion may not be necessary if the patient's concerns can be addressed through education and counseling.
- Choice D is incorrect as not all cesarean deliveries lead to complications in subsequent pregnancies.
An emergency cesarean is being implemented. The patient describes tingling in her ears and a metallic taste with the administration of regional anesthesia. The nurse is aware that which incidence has occurred?
- A. Manifestation of maternal respiratory depression related to anesthesia
- B. Inadvertent injection of the anesthetic agent into the maternal bloodstream
- C. Maternal hypotension is occurring related to administration of anesthesia
- D. Expected manifestations related to anesthetic medications are present
Correct Answer: B
Rationale: The correct answer is B: Inadvertent injection of the anesthetic agent into the maternal bloodstream. This is indicated by the patient experiencing tingling in her ears and a metallic taste, which are signs of systemic toxicity from the anesthetic agent. The anesthetic has entered the bloodstream instead of staying localized to the intended area. Other choices are incorrect as A is more related to opioid overdose, C is more related to hypotension, and D implies that these symptoms are normal when they are not.
The nurse is assessing the client for the presence of ballottement. Which should the nurse perform to test for the presence of ballottement?
- A. Palpate the uterus for contractions
- B. Assess the skin for increased pigmentation
- C. Initiate a gentle upward tap on the cervix
- D. Palpate the abdomen for fetal outline
Correct Answer: C
Rationale: The correct answer is C. To test for the presence of ballottement, the nurse should initiate a gentle upward tap on the cervix. Ballottement is a technique used in obstetrics to assess for the presence of a floating object in the uterus, such as a fetus. By tapping the cervix gently, the nurse can feel for a rebound effect, indicating the presence of a floating object. This technique helps to confirm the presence of a fetus in the uterus.
Explanation of why other choices are incorrect:
A: Palpating the uterus for contractions is not relevant to testing for ballottement.
B: Assessing the skin for increased pigmentation is not related to assessing for the presence of a floating object in the uterus.
D: Palpating the abdomen for fetal outline does not specifically test for ballottement, which involves tapping the cervix.
The nurse is concerned that a patient’s uterine activity is too intense and that her obesity is
preventing accurate assessment of the actual intrauterine pressure. Based on this information,
which action should the nurse take?
- A. Reposition the tocotransducer.
- B. Reposition the Doppler transducer.
- C. Obtain an order from the health care provider for a spiral electrod
- D. Obtain an order from the health care provider for an intrauterine pressure catheter.
Correct Answer: D
Rationale: The correct answer is D: Obtain an order from the health care provider for an intrauterine pressure catheter. This is the most appropriate action because an intrauterine pressure catheter provides the most accurate assessment of intrauterine pressure, especially in cases where obesity may interfere with external monitoring methods. Repositioning the tocotransducer (choice A) or Doppler transducer (choice B) may not significantly improve accuracy in this situation. Obtaining an order for a spiral electrod (choice C) is not necessary as it does not directly address the issue of accurate intrauterine pressure assessment.