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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The fetal heart rate baseline increases 20 bpm after vibroacoustic stimulation. The best interpretation of this is that the fetus is showing
- A. a worsening hypoxi
- B. progressive acidosis.
- C. an expected respons
- D. parasympathetic stimulation.
Correct Answer: C
Rationale: The correct answer is C. After vibroacoustic stimulation, an increase in fetal heart rate baseline indicates an expected response, showing the fetus is healthy and responding appropriately to the stimulus. This increase is a sign of fetal well-being and does not suggest worsening hypoxia (choice A) or progressive acidosis (choice B). Additionally, parasympathetic stimulation (choice D) would typically lead to a decrease in heart rate, not an increase as observed in this scenario. Therefore, choice C is the best interpretation based on the positive response of the fetal heart rate to the stimulation, indicating a healthy and expected reaction.
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.
The nurse is instructing a nursing student on the application of fetal monitoring devices. Which method of assessing the fetal heart rate requires the use of a gel?
- A. Doppler
- B. Fetoscope
- C. Scalp electrode
- D. Tocodynamometer
Correct Answer: A
Rationale: The correct answer is A: Doppler. Doppler requires the use of a gel to enhance the transmission of sound waves for accurate assessment of the fetal heart rate. Gel helps to eliminate air between the Doppler probe and the skin, improving signal quality. Fetoscope (B) is a direct listening device; Scalp electrode (C) and Tocodynamometer (D) do not require gel for fetal heart rate assessment.
A nurse is taking a birth history assessment on a client who is 8 weeks gestation and has one child who was born at 38 weeks. Which is consistent with this birth history?
- A. Primipara
- B. Primigravida
- C. Nulligravida
- D. Multipara
Correct Answer: D
Rationale: The correct answer is D: Multipara. This term refers to a woman who has given birth to two or more children. In this case, the client has one child already, making her a multipara.
A: Primipara refers to a woman who has given birth to one child, which does not match the client's birth history.
B: Primigravida refers to a woman who is pregnant for the first time, which also does not match the client's history.
C: Nulligravida refers to a woman who has never been pregnant, which is not the case for the client.
Therefore, the correct term to describe the client's birth history is Multipara, as she has one child and is currently 8 weeks gestation.
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.