Nokea
The nurse is explaining the medication options available for pain relief during labor. The nurse realizes the client needs further teaching when the client states which of the following?
- A. Nubain (nalbuphine) and Phenergan (promethazine) will give relief from pain and nausea during early labor.'
- B. I can have an epidural as soon as I start contracting.'
- C. If I have a cesarean, I can have an epidural.'
- D. If I have an emergency cesarean, I may be put to sleep for the delivery.'
Correct Answer: B
Rationale: Epidurals are typically administered in active labor (e.g., 4–5 cm dilation), not immediately upon contracting, indicating a need for further teaching. The other statements are accurate regarding pain relief options.
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A primiparous client who delivered a viable term neonate vaginally 48 hours ago has a midline episiotomy and a third-degree laceration. When preparing the client for discharge, which of the following assessments would be most important?
- A. Constipation.
- B. Diarrhea.
- C. Excessive bleeding.
- D. Rectal fistulas.
Correct Answer: C
Rationale: Excessive bleeding is critical to assess due to the risk of hemorrhage with a third-degree laceration.
After the nurse instructs a 20-year-old nulligravid client on how to perform a breast self-examination, which of the following client statements indicates that the teaching has been successful?
- A. I should perform breast self-examination on the day my menstrual flow begins.
- B. It's important that I perform breast self-examination on the same day each month.
- C. If I notice that one of my breasts is much smaller than the other, I shouldn't worry.
- D. If there is discharge from my nipples, I should call my health care provider.
Correct Answer: D
Rationale: Breast self-examination should be performed about a week after the menstrual period begins, when breasts are least tender. Noticing nipple discharge is a concerning symptom that warrants contacting a healthcare provider, indicating successful teaching.
On arrival at the emergency department, a client tells the nurse that she suspects that she may be pregnant but has been having a small amount of bleeding and has severe pain in the lower abdomen. The client's blood pressure is 70/50 mm Hg and her pulse rate is 120 bpm. The nurse notifies the physician immediately because of the possibility of:
- A. Ectopic pregnancy.
- B. Abruptio placentae.
- C. Gestational trophoblastic disease.
- D. Complete abortion.
Correct Answer: A
Rationale: Severe pain and hypotension suggest ectopic pregnancy.
The nurse discovers a medication error where a postpartum client received 400 mg of ibuprofen instead of 800 mg. The nurse should:
- A. Monitor the client for adverse effects.
- B. Administer the remaining 400 mg immediately.
- C. Notify the physician and complete an incident report.
- D. Document the dose as administered without reporting.
Correct Answer: C
Rationale: Notifying the physician and filing an incident report ensures patient safety and proper follow-up.
While the nurse is caring for a primiparous client on the first postpartum day, the client asks, "How is that woman doing who lost her baby from prematurity?" Which of the following responses by the nurse would be most appropriate?
- A. Ignore the client's question and continue with morning care.
- B. Tell the client "I'm not sure how the other woman is doing today."
- C. Tell the client "I need to ask the woman's permission before discussing her well-being."
- D. Explain to the client that "Nurses are not allowed to discuss other clients on the unit."
Correct Answer: D
Rationale: Nurses must maintain patient confidentiality, making it inappropriate to discuss another client's status.