Nokea
The nurse just administered butorphanol tartrate as prescribed to the client in active labor. Following administration of butorphanol tartrate, what is the nurse’s most important action to help prevent side effects?
- A. Assess the client’s bladder for distention
- B. Place the client on seizure precautions
- C. Assess the client’s body for itchy rash
- D. Evaluate her vital signs and pulse oximetry
Correct Answer: D
Rationale: Evaluating maternal VS and pulse oximetry would determine changes in respiratory and cardiac status. Respiratory depression in both the mother and fetus can occur with butorphanol tartrate (Stadol). Although bladder distention is a possible side effect of butorphanol tartrate, it is not common and is not the most important assessment. Seizures are not a potential side effect of butorphanol tartrate. An itchy rash is not a potential side effect of butorphanol tartrate.
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Which finding indicates a need for further evaluation during a prenatal visit?
- A. Blood pressure of 120/80 mmHg
- B. Trace protein in urine
- C. Weight gain of 1 pound per week
- D. Fetal heart rate of 140 bpm
Correct Answer: B
Rationale: Trace protein in urine may indicate early preeclampsia or kidney issues, warranting further evaluation.
The client, who had preeclampsia and delivered vaginally 4 hours ago, is still receiving magnesium sulfate IV. When assessing the client’s deep tendon reflexes (DTRs), the nurse finds that they are both weak, at 1+, whereas previously they were 2+ and 3+. Which actions should the nurse plan? Select all that apply.
- A. Notify the client’s HCP about the reduced DTRs.
- B. Prepare to increase the magnesium sulfate dose.
- C. Prepare to administer calcium gluconate IV.
- D. Assess the level of consciousness and vital signs.
- E. Ask the HCP about drawing a serum calcium level.
Correct Answer: A,C,D
Rationale: The HCP should be notified about the decreased DTRs because weakening of these may indicate magnesium sulfate toxicity. Increasing the magnesium sulfate dose would worsen the situation and could lead to a depressed respiratory rate. Any time the client is receiving a magnesium sulfate infusion, the nurse should be prepared for the possibility of needing the antidote, calcium gluconate. The nurse should assess the client’s vital signs and level of consciousness, as decreased level of consciousness and respiratory effort are serious side effects of magnesium sulfate. The nurse should ask the HCP about drawing a serum magnesium level (not a serum calcium level) to determine whether the client is experiencing magnesium toxicity.
The nurse is caring for the client who just gave birth. Which observation of the client should lead the nurse to be concerned about the client’s attachment to her male infant?
- A. Asking the caregiver about how to change his diaper
- B. Comparing her newborn’s nose to her brother’s nose
- C. Calling the baby “Kelly,” which was the name selected
- D. Repeatedly telling her husband that she wanted a girl
Correct Answer: D
Rationale: Seeking information about infant care is a sign that the mother is developing attachment to her infant. Pointing out family traits or characteristics seen in the newborn is a sign that the mother is developing attachment. Calling the infant by name is a sign that the mother is developing attachment to her infant. Attachment is demonstrated by expressing satisfaction with a baby’s appearance and sex. Frequent expressions of dissatisfaction with the sex of the infant should be concerning and followed up.
After delivering the full-term infant, the breastfeeding mother asks the nurse if there is any contraceptive method that she should avoid while she is breastfeeding. Which contraceptive should the nurse advise the client to avoid?
- A. A diaphragm
- B. An intrauterine device (IUD)
- C. The combined oral contraceptive (COC) pill
- D. The progesterone-only mini pill
Correct Answer: C
Rationale: Because a diaphragm must be fitted to the individual female cervix, the diaphragm must be rechecked for correct size after each childbirth; however, use of the diaphragm will not affect breast milk production. An IUD will not affect breast milk production unless the IUD is inserted within the first 48 hours postpartum; insertion should be delayed until 4 weeks postpartum. Birth control pills containing progesterone and estrogen (COC) can cause a decrease in milk volume and may affect the quality of the breast milk. The progesterone-only mini pill may be used by breastfeeding clients because it does not interfere with breast milk production. However, it is recommended that the mother wait 6 to 8 weeks before starting this method of contraception.
The 42-year-old client who had a partial hydatidiform molar pregnancy 3 months ago asks the nurse whether she and her husband can try conceiving again. Which response by the nurse is incorrect and warrants follow-up action by the observing nurse manager?
- A. “You will need serial levels of beta human chorionic gonadotropin (BHCG) drawn.”
- B. “You cannot conceive ever again because of your risk of choriocarcinoma.”
- C. “You should not become pregnant yet for 6 to 12 months.”
- D. “Your risk of another hydatidiform molar pregnancy is low.”
Correct Answer: B
Rationale: Women who have had a molar pregnancy can conceive again once their BHCG levels are normal and remain normal for a certain time period, usually 6 to 12 months. This response by the nurse is incorrect and should be followed up by the observing nurse manager. Because of the risk of choriocarcinoma, serial serum BHCG testing is completed after a hydatidiform molar pregnancy. Because the client will undergo serial serum BHCG testing after a hydatidiform molar pregnancy, she should not get pregnant for 6 to 12 months until testing is completed and it is confirmed that she does not have a malignancy. Couples with a past history of molar pregnancy have the same statistical chance of conceiving again and having a normal pregnancy as those without.