Nokea
The laboring client just had a convulsion after being given regional anesthesia. Which interventions should the nurse implement? Select all that apply.
- A. Establish an airway.
- B. Position on her right side.
- C. Provide 100% oxygen.
- D. Administer diazepam.
- E. Page the anesthesiologist STAT.
Correct Answer: A,C,D,E
Rationale: The client experiencing a convulsion related to anesthesia should first have an airway established. The client experiencing a convulsion related to anesthesia should receive 100% oxygen so that the mother and fetus remain oxygenated. Small doses of diazepam or thiopental can be administered to stop the convulsions. The anesthesiologist should be STAT paged to provide assistance; the convulsion was initiated by the regional anesthetic. The client’s head should be turned to the side if vomiting occurs, but the client typically remains in a left lateral tilt position so an airway can be maintained. Positioning on the right side can cause aortocaval compression.
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Which nursing instructions concerning exercise during pregnancy are accurate? Select all that apply.
- A. Avoid exercising during hot, humid weather.
- B. Avoid exercises involving bouncing or jumping movements.
- C. Drink plenty of fluids before and after exercising.
- D. Limit strenuous activity to no more than 60 minutes a session.
- E. Perform exercises only in the supine position.
- F. Limit exercising to once per week.
Correct Answer: A,B,C
Rationale: Exercising in hot weather risks overheating, bouncing movements may strain joints, and hydration is crucial. Supine exercises are avoided late in pregnancy.
The client tells the nurse, “Most days, I am so happy I am pregnant, but other days, I am not sure that I am ready to have a baby.” Which is the most accurate response from the nurse?
- A. “This is such a happy time in your life. You need to be optimistic to feel happy.”
- B. “How does your spouse feel about the pregnancy? I hope he is happy about the baby.”
- C. “Feeling differently from day to day is normal. How do you feel today?”
- D. “Why do you feel this way? Is there something I can do to make it better for you?”
Correct Answer: C
Rationale: It is most therapeutic to acknowledge the client’s feelings and probe for more information on her thoughts and feelings about the pregnancy. Not all clients consider pregnancy a happy time in their lives, and the nurse should never tell the client how to feel. The nurse should not divert the client’s concerns away from self by bringing up the father’s adaptation to the pregnancy, even though paternal adaptation is related to maternal adaptation. The client may not be able to identify why she has the feelings she is experiencing or how the nurse can make her feel better. This response does not provide an avenue for further exploration of the client’s concerns.
The student nurse reports to an experienced nurse finding a warm, red, tender area on the left calf of the client who is 48 hours post—vaginal delivery. The nurse assesses the client and explains to the student that postpartum clients are at increased risk for thrombophlebitis due to which factors? Select all that apply.
- A. The fibrinogen levels in the blood of postpartum clients are elevated.
- B. Fluids normally shift from the interstitial to the intravascular space.
- C. Postpartum hormonal shifts irritate vascular basement membranes.
- D. Pressure is placed on the legs when elevated in stirrups during delivery.
- E. Dilation of veins in the lower extremities occurs during pregnancy.
- F. Compression of the common iliac vein occurs during pregnancy.
Correct Answer: A,D,E,F
Rationale: During pregnancy, fibrinogen levels increase, and this increase continues to be present in the postpartum period. The increased levels can contribute to clot formation. There is not a shift of fluid from the interstitial to the vascular spaces in the postpartum period. Actual blood volume increases during pregnancy and is further increased immediately after delivery. This fluid volume is eventually lost through diuresis during the first postpartum week. Postpartum hormonal changes do occur, but they do not affect the vascular basement membranes. Elevation of the legs in stirrups during delivery leads to pooling of blood and vascular stasis. Dilation of the veins in the lower extremities occurs during pregnancy and increases the risk of venous stasis. Compression of the common iliac vein occurs during pregnancy due to an enlarging fetus and increases the risk of venous stasis.
The nurse is caring for the 30-weeks-pregnant client who is having contractions every 1½ to 2 minutes with spontaneous rupture of membranes 2 hours ago. Her cervix is 8 cm dilated and 100% effaced. The nurse determines that delivery is imminent. What intervention is the most important at this time?
- A. Administering a tocolytic agent
- B. Providing teaching information on premature infant care
- C. Notifying neonatology of the impending birth
- D. Preparing for a cesarean section birth
Correct Answer: C
Rationale: The most important intervention is to notify the neonatal team of the delivery because the team members will be needed for respiratory support and possible resuscitation. Tocolytic agents, such as nifedipine (Procardia), can be used for short-term intervention to slow down contractions and delay birth, but it is too late to administer a tocolytic agent. Teaching is important but is not appropriate at this time. A cesarean birth is indicated if there are other obstetrical needs.
The nurse is preparing to administer 2 mg hydromorphone hydrochloride to the client who is 28 hours post—cesarean section. The medication available is in a concentration of 4 mg/mL. How many milliliters should the nurse administer?
- A. 0.5 mL
- B. 1.0 mL
- C. 2.0 mL
- D. 4.0 mL
Correct Answer: 0.5 mL
Rationale: (2 mg / 4 mg) x 1 mL = 0.5 mL. The nurse should administer 0.5 mL hydromorphone hydrochloride (Dilaudid).