Nokea
The nurse is caring for a postpartal client who is exhibiting symptoms of a spinal headache 24 hours following delivery of a normal newborn. Prior to the anesthesiologist's arrival on the unit, which action should the nurse perform?
- A. Cleanse the spinal injection site
- B. Apply an abdominal binder
- C. Insert an indwelling Foley catheter
- D. Place procedure equipment at bedside
Correct Answer: D
Rationale: Preparing procedure equipment, such as for a blood patch, ensures readiness for the anesthesiologist to address the spinal headache effectively.
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The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn's survival?
- A. Bleeding tendencies
- B. Heat loss
- C. Hypoglycemia
- D. Fluid balance
Correct Answer: B
Rationale: Newborns are at high risk for hypothermia due to heat loss, which can compromise survival. Preventing heat loss is a priority immediately after birth.
A client at 18-weeks gestation was informed this morning that she has an elevated alpha-fetoprotein (AFP) level. After the healthcare provider leaves the room, the client asks what she should do next. What information should the nurse provide?
- A. Discuss options for intrauterine surgical correction of congenital defects.
- B. Inform her that a repeat alpha-fetoprotein (AFP) should be evaluated.
- C. Reassure the client that the AFP results are likely to be a false reading.
- D. Explain that a sonogram should be scheduled for definitive results
Correct Answer: D
Rationale: An elevated AFP level is a screening indicator, not a diagnosis. A sonogram is the next step to assess for neural tube defects or other anomalies, providing definitive information.
A client who had her first baby three months ago and is breastfeeding her infant tells the nurse that she is currently using the same diaphragm that she used before becoming pregnant. Which information should the nurse provide this client?
- A. After ceasing breastfeeding the diaphragm should be resized.
- B. Use an alternate form of contraception until a new diaphragm is obtained.
- C. If no more than 20 pounds was gained during pregnancy, the diaphragm is safe to use.
- D. Avoid intercourse during ovulation until the size of the diaphragm has been evaluated
Correct Answer: B
Rationale: Pregnancy and childbirth can alter vaginal anatomy, making a pre-pregnancy diaphragm ineffective. An alternate contraception method is needed until a new diaphragm is fitted.
A client who delivered vaginally 2 days ago states that she wants to resume using her diaphragm for birth control. What information should the nurse share with her?
- A. The diaphragm must be refitted after childbirth
- B. The most effective form of contraception is a diaphragm
- C. The diaphragm should be inserted 2 to 4 hours before intercourse.
- D. Vaseline lubricant can be used when inserting the diaphragm
Correct Answer: A
Rationale: Childbirth can alter vaginal and cervical anatomy, requiring the diaphragm to be refitted for effective contraception.
A pregnant client receives Rho(D) immune globulin after an amniocentesis. The day following the procedure the client calls the nurse to report a temperature of 99.8° F (37.67°C). Which action should the nurse implement?
- A. Instruct the client to maintain bed rest for 24 hours.
- B. Encourage the client to increase her intake of oral fluids
- C. Schedule a visit with the healthcare provider today
- D. Verify the administered Rho(D) immune globulin's compatibility
Correct Answer: C
Rationale: A temperature elevation post-amniocentesis may indicate infection, requiring prompt evaluation by a healthcare provider.