Nokea
The nurse is caring for the pregnant client. The nurse identifies that the use of which street drug places the client at risk for placental abruption?
- A. Heroin
- B. Marijuana
- C. Oxycodone
- D. Cocaine
Correct Answer: D
Rationale: The most commonly used drug that places the pregnant client at risk for placental abruption is cocaine. Stillbirth, preterm labor and birth, and small for gestational age are also associated with cocaine use during pregnancy. Heroin use during pregnancy is associated with intrauterine growth restriction, spontaneous abortion, preterm labor and birth, and stillbirth. Marijuana use during pregnancy is primarily associated with intrauterine growth restriction. Oxycodone (OxyContin) is synthetic morphine, and its use during pregnancy is associated with intrauterine growth restriction, spontaneous abortion, preterm labor and birth, and stillbirth.
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The nurse is evaluating the client in triage for possible labor. The client’s contractions are every 3 to 4 minutes, 60 to 70 seconds in duration, and moderate by palpation. Her cervical exam in the office was illustration 1. Her current exam is illustration 2. What conclusions should the nurse draw from illustration 2?
- A. The client is not dilated or effaced.
- B. The client is completely dilated but not effaced.
- C. The client has minimally dilated, but completely effaced.
- D. The client is not dilated, but completely effaced.
Correct Answer: C
Rationale: In illustration 2, the client is completely effaced and has some dilation. Illustration 1 (not illustration 2) shows that the client is neither effaced nor dilated. The cervical opening is minimally dilated, not completely dilated, and completely effaced. Illustration 2 shows some dilation.
The laboring client is experiencing problems, and the nurse is concerned about possible side effects from the epidural anesthetic just administered. Which problems should the nurse attribute to the epidural anesthetic? Select all that apply.
- A. Has breakthrough sharp pain
- B. Blood pressure is increased
- C. Has a pounding headache
- D. Unable to feel a full bladder
- E. Has an elevated temperature
Correct Answer: A,C,D,E
Rationale: Breakthrough pain can occur when the continuous infusion rate of the anesthetic agent is below the recommended rate for a therapeutic dose. Breakthrough pain can also occur when the client has a full bladder or when the cervix is completely dilated. A spinal headache can be a complication of epidural anesthesia and occurs when the dura is accidently punctured during epidural placement. A sensory level of T10 is usually maintained during epidural anesthesia; most women are unable to feel a full bladder or to void after receiving an epidural anesthetic. Maternal temperature may be elevated to 100.1°F (37.8°C) or higher with an epidural. Sympathetic blockade may decrease sweat production and diminish heat loss. Hypertension is a contraindication for epidural anesthesia. A major side effect of epidural anesthesia is hypotension (not hypertension) caused by a spinal blockade, which lowers peripheral resistance, decreases venous return to the heart, and subsequently lessens cardiac output and lowers BP.
The postpartum client delivered a healthy newborn 36 hours previously. The nurse finds the client crying and asks what is wrong. The client replies, “Nothing, really. I’m not in pain or anything, but I just seem to cry a lot for no reason.” What should be the nurse’s first intervention?
- A. Call the client’s support person to come and sit with her.
- B. Remind her that she has a healthy baby and that she shouldn’t be crying.
- C. Contact the HCP to have the counselor come see the client.
- D. Ask the client to discuss her birth experience.
Correct Answer: D
Rationale: The client’s support person should be given information about postpartum blues before the client is discharged from the hospital. However, contacting that individual should not be the first intervention. Reminding the client that she has a healthy baby is a nontherapeutic communication technique that implies disapproval of the client’s actions. There is no need to notify the HCP, as postpartum blues is a common self-limiting postpartum occurrence. A key feature of postpartum blues is episodic tearfulness without an identifiable reason. Interventions for postpartum blues include allowing the client to relive her birth experience.
The client has a vaginal delivery of a full-term newborn. Immediately after delivery, the nurse assesses that the client’s perineum and labia are edematous, but she does not have an episiotomy or a perineal laceration. Which intervention should the nurse implement?
- A. Give her an ice pack to apply to the perineum.
- B. Teach her to relax her buttocks before sitting.
- C. Apply warm packs to the affected areas.
- D. Provide a plastic donut cushion for sitting.
Correct Answer: A
Rationale: If perineal edema is present, ice packs should be applied for the first 24 hours. Ice reduces edema and vulvar irritation. The client should be taught to tighten, not relax, her buttocks when sitting. This compresses the buttocks and reduces pressure on the perineum. After 24 hours, heat is recommended to increase circulation to the area. Donut cushions should be avoided because they promote separation of the buttocks and decrease venous blood flow to the area, thus increasing pain.
The nurse teaches the client to recognize which early labor sign?
- A. Bloody show
- B. Fatigue
- C. Increased appetite
- D. Mild nausea
Correct Answer: A
Rationale: Bloody show, a mucous discharge tinged with blood, is a common early labor sign as the cervix begins to dilate.