Nokea
Two hours after an epidural infusion has begun the patient complains of itching of her face and neck. The nurse should:
- A. Recognize this is a common side effect to follow protocol for administration of Benadryl
- B. Remove the epidural catheter and apply a band aid on the injection site
- C. Offer the patient a cool cloth and let her know itching is temporary
- D. Call anesthesia to remove epidural catheter
Correct Answer: A
Rationale: Itching of the face and neck following an epidural infusion is a common side effect known as pruritus. The nurse should recognize this symptom and follow the protocol for addressing itching associated with epidural infusions. In this case, administering Benadryl is a common intervention to help relieve the itching. Benadryl is an antihistamine that can help alleviate itching and discomfort without the need to remove the epidural catheter. It is important for the nurse to assess the patient's symptoms, follow proper protocols, and provide appropriate interventions to manage side effects like pruritus.
You may also like to solve these questions
Which health concern is most likely to be an issue for the older mother?
- A. Nutrition and diet planning
- B. Exercise and fitness
- C. Having enough rest and sleep
- D. Effective contraceptive methods
Correct Answer: A
Rationale: As women age, their nutritional needs may change, and they may require more specific nutrients to support their health. Older mothers may be more susceptible to health concerns related to inadequate nutrition and diet planning, such as osteoporosis or heart disease. Proper nutrition is essential for both the mother's well-being and the health of her child. Therefore, nutrition and diet planning are more likely to be an issue for an older mother compared to exercise, rest, or contraceptive methods, especially during pregnancy and postpartum periods.
The nurse is caring for a client with suspected placenta previa. What is the priority nursing intervention?
- A. Perform a sterile vaginal examination.
- B. Monitor fetal heart rate and maternal vital signs.
- C. Administer oxytocin to stop the bleeding.
- D. Encourage the client to ambulate.
Correct Answer: B
Rationale: Monitoring maternal and fetal well-being is critical in cases of placenta previa to detect complications.
The nurse is caring for a client pregnant with twins. Which statement indicates that the client needs additional information?
- A. Because both of my twins are boys, I know that they are identical.
- B. If my twins came from one fertilized egg that split, they are identical.
- C. If I have one boy and one girl, I will know they came from two eggs.
- D. It is rare for both twins to be within the same amniotic sac.
Correct Answer: A
Rationale: The statement 'Because both of my twins are boys, I know that they are identical' is incorrect because twins can be fraternal and of the same sex. Identical twins result from one fertilized egg splitting, while fraternal twins result from two separate fertilized eggs.
Which of the following best describes the mechanism of action of birth control pills?
- A. They block sperm from reaching the egg.
- B. They prevent ovulation by suppressing hormone levels.
- C. They increase cervical mucus production to block sperm entry.
- D. They reduce the size of the ovaries and fallopian tubes to prevent pregnancy.
Correct Answer: B
Rationale: Birth control pills primarily work by preventing ovulation, thereby inhibiting the release of eggs for fertilization. Choice A is incorrect because birth control pills do not directly block sperm; they prevent ovulation. Choice C is partially correct but is not the main mechanism, as the primary function is to prevent ovulation. Choice D is incorrect because birth control pills do not alter the size of reproductive organs.
The nurse is assessing a client at 20 weeks' gestation with suspected anemia. What lab finding supports this diagnosis?
- A. Hemoglobin of 10 g/dL.
- B. Platelet count of 150,000 mm3.
- C. Hematocrit of 40%.
- D. White blood cell count of 8,000 mm3.
Correct Answer: A
Rationale: A hemoglobin level of 10 g/dL is below normal during pregnancy and indicates anemia.