Nokea
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.
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Which nursing intervention can help prevent postpartum depression?
- A. Provide printed educational material
- B. Encourage the mother to join a support group
- C. Assess the mother for risk factors of depression
- D. Administer antidepressants as prescribed
Correct Answer: B
Rationale: The correct answer is B because joining a support group can provide emotional support and reduce feelings of isolation, which are key factors in preventing postpartum depression. Printed educational material (A) may not offer personalized support. Assessing for risk factors (C) is important but alone may not prevent depression. Administering antidepressants (D) is a treatment, not a prevention strategy.
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.
The nurse is counseling a client on the proper con- admitted to the labor and delivery unit complaining sumption of fish and fish products while pregnant. of mild contractions that are 10 minutes apart. How much fish should the nurse instruct the client After performing Leopold's maneuvers, the nurse to eat? determines that a hard round object is in the uterine
- A. 8 to 12 ounces of a variety of fish every week fundus. What should the nurse do if green fluid is
- B. 8 to 12 ounces of a variety of fish every month noted after rupture of the fetal membranes?
- C. 12 to 16 ounces of a variety of fish every week A.Observe the fetal monitor for variable decelerations
- D. 12 to 16 ounces of a variety of fish every month
Correct Answer: C
Rationale: The correct answer is C: 12 to 16 ounces of a variety of fish every week. During pregnancy, fish is a good source of protein and omega-3 fatty acids which are beneficial for fetal development. Consuming 12 to 16 ounces per week is recommended by health authorities for pregnant women to get essential nutrients without excessive mercury intake. Choice A (8 to 12 ounces of fish every week) is not enough for optimal nutrition during pregnancy. Choice B (8 to 12 ounces of fish every month) is too infrequent for consistent nutrient intake. Choice D (12 to 16 ounces of fish every month) is also inadequate as the frequency is not sufficient for optimal fetal development. Therefore, choice C is the best option for ensuring adequate nutrient intake while minimizing risks associated with mercury consumption.
The nurse is assessing a postpartum client. Which finding requires immediate intervention?
- A. Fundus firm and midline.
- B. Lochia rubra with large clots.
- C. Mild swelling in the perineal area.
- D. Breast tenderness on day 2 postpartum.
Correct Answer: B
Rationale: The correct answer is B because Lochia rubra with large clots could indicate excessive bleeding, which is a postpartum hemorrhage and requires immediate intervention to prevent further complications. A: Fundus firm and midline is a normal finding. C: Mild swelling in the perineal area is expected after childbirth. D: Breast tenderness on day 2 postpartum is a common finding due to milk production starting.
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.