Nokea
The nurse is caring for a client in labor with an epidural. What assessment is most important immediately after placement?
- A. Monitor maternal temperature.
- B. Assess for lower extremity weakness.
- C. Monitor maternal blood pressure.
- D. Check fetal presentation.
Correct Answer: C
Rationale: Maternal blood pressure monitoring is essential to detect and manage hypotension caused by epidural anesthesia.
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A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?
- A. Vomiting
- B. Tachycardia
- C. Respiratory depression
- D. Hypotension
Correct Answer: D
Rationale: Epidural anesthesia can cause hypotension as a common complication. This occurs because the local anesthetic affects the sympathetic nerves, leading to vasodilation and subsequent lowering of blood pressure. It is crucial for nurses to monitor the client's blood pressure closely and be prepared to administer IV fluids or medications to address the hypotension promptly. Vomiting, tachycardia, and respiratory depression are not typically associated with epidural anesthesia; therefore, hypotension is the most likely complication to be identified in this scenario.
Which of the following is a unique risk factor for substance misuse in individuals AFAB?
- A. Genetic predisposition
- B. High socioeconomic status
- C. Regular physical exercise
- D. History of trauma
Correct Answer: D
Rationale:
A nurse is caring for a client who is in the transition phase of labor and reports a pain level of 7 on a scale of 0 to Which of the following actions should the nurse take?
- A. Instruct the client to use effleurage
- B. Apply counter pressure to the client sacral.
- C. Assist the client with patterned-paced breathing.
- D. Teach the client the technique of biofeedback.
Correct Answer: B
Rationale: In the transition phase of labor, the contractions are intense and the client may experience significant discomfort and pain. Applying counter pressure to the client's sacral area can help alleviate this pain by providing some relief and support. Counter pressure involves applying firm pressure with the palms or fists to the lower back or sacral area during contractions. This technique can help to relieve some of the pressure and discomfort experienced during contractions, making it a beneficial action for the nurse to take in this situation.
Which newborn is at highest risk of a skin infection? of the FHR?
- A. Infant born at 36 weeks who is being bottle fed
- B. Right lower abdomen
- C. Infant whose umbilical cord fell off on day 8 of life
- D. Near client umbilicus
Correct Answer: C
Rationale: The newborn infant whose umbilical cord fell off on day 8 of life is at highest risk of a skin infection. This is because the umbilical cord stump is an area prone to bacterial colonization and can lead to infection if proper care is not maintained during the cord care period. Once the umbilical cord falls off, the skin in that area is exposed and vulnerable to infection. It is important to educate parents on proper cord care techniques to prevent infection in this high-risk period.
The nurse is caring for a client in the second stage of labor. What assessment indicates that birth is imminent?
- A. Cervix is dilated to 8 cm.
- B. Fetal head is crowning.
- C. Contractions every 3–5 minutes.
- D. Client reports back pain.
Correct Answer: B
Rationale: Crowning occurs when the fetal head becomes visible at the vaginal opening, indicating that birth is imminent.