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A nurse is assisting with the care of a client who is in labor and has an epidural infusion for pain management. The client's blood pressure is 80/40 mm Hg.
Which of the following actions should the nurse take?
- A. Assist the client to empty her bladder.
- B. Place the client in knee chest position
- C. Administer methylergonovine IM
- D. Give a bolus of lactated Ringer's
Correct Answer: D
Rationale: The client's blood pressure is low (80/40 mm Hg), indicating hypotension, a common side effect of epidural anesthesia during labor. Administering a bolus of intravenous fluids, such as lactated Ringer's solution, is the initial intervention to increase intravascular volume, improving blood pressure and perfusion to vital organs.
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A nurse is caring for a client who had a vaginal delivery 4 hr ago and reports perineal pain of 6 on a scale of 0 to 10.
Which of the following actions should the nurse take?
- A. Offer an ice pack to the client during the first 24 hr.
- B. Apply a corticosteroid cream to the perineal area twice daily.
- C. Increase the client's fluid intake for 48 hr.
- D. Catheterize the client's bladder.
Correct Answer: A
Rationale: Offering an ice pack reduces inflammation and numbs the perineal area, providing effective pain relief in the immediate postpartum period after vaginal delivery.
A nurse is assisting in the care of a client who is 3 hours postpartum and reports complete saturation of their perineal pad in the past 30 minutes.
Which of the following actions is the highest priority?
- A. Perform fundal massage
- B. Weigh the perineal pad
- C. Apply oxygen by face mask
- D. Monitor urine output
Correct Answer: A
Rationale: Complete saturation of the perineal pad within 30 minutes postpartum suggests excessive bleeding, potentially indicating postpartum hemorrhage. Fundal massage stimulates uterine contractions to control bleeding by compressing blood vessels at the placental site, making it the highest priority action.
A nurse is reinforcing teaching about car seat safety with a parent of a newborn.
Which of the following statements by the parent indicates an understanding of the teaching?
- A. I should place my baby in the car seat at a 90-degree angle.
- B. I will place a thick, soft pad behind my baby's back.
- C. I can turn the car seat so it faces forward when my baby weighs 15 pounds.
- D. I will place the retainer clip at the level of my baby's armpits
Correct Answer: D
Rationale: Placing the retainer clip at the armpit level ensures proper harness positioning, providing optimal protection in a crash, indicating understanding of car seat safety.
A nurse is reinforcing teaching about outpatient resources for a client who is recovering from a molar pregnancy.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I will need to start chemotherapy immediately.
- B. I will need to attend a support group when I get home.
- C. I will need an amniocentesis within 1 month.
- D. I will need home palliative services after I am discharged from the hospital.
Correct Answer: B
Rationale: Attending a support group provides emotional support and coping strategies post-molar pregnancy, reflecting an understanding of the psychosocial resources available.
A nurse is collecting data from a client who is at 26 weeks of gestation and whose last appointment was 1 month ago.
Which of the following findings should the nurse report to the provider?
- A. Pedal edema
- B. BP of 132/84 mm Hg
- C. Weight gain of 1 kg (2.2 lb)
- D. Double vision
Correct Answer: D
Rationale: Double vision can indicate preeclampsia or other serious conditions in pregnancy, requiring prompt reporting for further evaluation and management.