Nokea
Woman received epidural or intrathecal opioids
The main nursing observations of the woman who receives epidural or intrathecal opioids are for all except
- A. delayed respiratory depression.
- B. inability to move lower extremities.
- C. pruritus.
- D. nausea and vomiting.
Correct Answer: A
Rationale: Delayed respiratory depression is not a primary concern with epidural or intrathecal opioids, which have limited systemic effects compared to systemic opioids.
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Woman post-spinal anesthesia, pounding headache rated 7/10
A woman had spinal anesthesia for delivery. Now she complains of a pounding headache rated 7/10. What action by the nurse is most appropriate?
- A. Place a cool cloth on her forehead and dim the room lights.
- B. Prepare to assist with a blood patch procedure.
- C. Increase the rate of her nonadditive IV fluids.
- D. Give the woman IV opioid pain medications.
Correct Answer: B
Rationale: A pounding headache post-spinal anesthesia suggests a spinal headache from cerebrospinal fluid leakage, best treated with a blood patch to seal the dural puncture.
Newborn 1 hour after birth
The nurse completes the initial assessment of a newborn. Which finding would lead the nurse to suspect that the newborn is experiencing difficulty with oxygenation?
- A. Acrocyanosis.
- B. Respiratory rate of 54 breaths/minute.
- C. Nasal flaring.
- D. Abdominal breathing.
Correct Answer: C
Rationale: Nasal flaring indicates difficulty with oxygenation, as it is a compensatory mechanism to increase airflow in respiratory distress.
Student nurse learning about milk production
The student nurse learns that the hormone necessary for milk production is
- A. Estrogen.
- B. Prolactin.
- C. Progesterone.
- D. Lactogen.
Correct Answer: B
Rationale: Prolactin, secreted by the pituitary gland, is responsible for milk production, especially after delivery when estrogen and progesterone levels drop.
Newborn, preventing heat loss
To prevent heat loss from convection in a newborn, which action by the nurse is best?
- A. Dry the baby after a bath.
- B. Wrap the baby in warmed blankets.
- C. Place the baby in a warmer.
- D. Move infant away from blowing fan.
Correct Answer: D
Rationale: Moving the infant away from a blowing fan directly prevents heat loss due to air movement, which is a key factor in convection.
Mother in labor, nonreassuring fetal heart rate pattern, lying on left side
The nurse notes a nonreassuring pattern of the fetal heart rate. The mother is already lying on her left side. What nursing action is indicated?
- A. Change her position to the right side.
- B. Place a wedge under the left hip.
- C. Lower the head of the bed.
- D. Place the mother in a Trendelenburg position.
Correct Answer: B
Rationale: Placing a wedge under the left hip is a common intervention to improve uteroplacental blood flow by tilting the uterus off the vena cava, enhancing venous return and cardiac output, which can positively affect fetal oxygenation.