Nokea
A nurse is assisting with the care of a client who is in labor and has received nalbuphine hydrochloride.
Which of the following manifestations should the nurse identify as an adverse effect of this medication?
- A. Fever
- B. Diuresis
- C. Diarrhea
- D. Sedation
Correct Answer: D
Rationale: Sedation is a common adverse effect of nalbuphine, an opioid analgesic, causing drowsiness or reduced alertness.
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History and Physical: Repeat caesarean birth 3 days ago, mastitis. Vital Signs: BP 130/84 mm Hg, HR 106/min, RR 20/min, Temp 38.94°C. Assessment: WBC 28,000/mm3, Hgb 13 g/dL, Hct 37%, redness/warmth in left breast, cracked nipples, body aches, chills, headache, breast tenderness.
The nurse is collecting data from the client 24 hr later. How should the nurse interpret the findings?
- A. Purulent nipple discharge: Sign of potential worsening condition
- B. Moderate lochia rubra: Unrelated to diagnosis
- C. Client reports decreased level of pain: Sign of potential improvement
- D. WBC count 35,000/mm3: Sign of potential worsening condition
- E. Temperature 38.4° C (101.1° F): Sign of potential improvement
- F. Hgb 12 g/dL: Unrelated to diagnosis
Correct Answer: A,C,D,E
Rationale: Purulent discharge and increased WBC suggest worsening mastitis, while decreased pain and lower temperature indicate improvement. Lochia and hemoglobin are unrelated to mastitis.
A nurse in a provider's office is reinforcing teaching with a client who is pregnant and is scheduled for a nonstress test.
Which of the following statements should the nurse make?
- A. You will not be able to eat or drink anything for 8 hours prior to the test.
- B. You will receive medication through an IV line to stimulate contractions.
- C. You will press the provided button when you feel the baby moving during the test.
- D. You will be required to lie flat on your back for the duration of the test.
Correct Answer: C
Rationale: During a nonstress test, the client presses a button when they feel fetal movement to monitor fetal heart rate response, assessing fetal well-being. No fasting, IV medication, or lying flat is required.
A nurse in an antepartum unit is assisting with the care of a client who has preeclampsia and is receiving IV magnesium sulfate therapy.
For which of the following adverse effects should the nurse monitor and report to the provider?
- A. Polyuria
- B. Hyporeflexia
- C. Agitation
- D. Tachypnea
Correct Answer: B
Rationale: Hyporeflexia is an early sign of magnesium toxicity, indicating excessive neuromuscular blockade, requiring immediate reporting.
A nurse is checking the reflexes of a newborn.
Which of the following actions should the nurse use to elicit the Babinski reflex?
- A. Stroke upward on the lateral aspect of the sole of the newborn's foot.
- B. Place the newborn supine and apply pressure to the soles of the feet.
- C. Pull the newborn up by the wrist from a supine position
- D. Touch the corner of the newborn's mouth
Correct Answer: A
Rationale: The Babinski reflex is elicited by stroking the lateral sole of the foot, causing dorsiflexion of the big toe and fanning of other toes in newborns.
A nurse is reinforcing teaching about breastfeeding with a client who is postpartum.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I will nurse my baby for 5 to 10 minutes on each breast.
- B. I will make sure that just the nipple is in my baby's mouth.
- C. I will lay my baby on a pillow at the level of my breast.
- D. I will apply vitamin E oil to my nipples after each feeding.
Correct Answer: C
Rationale: Positioning the baby at breast level with a pillow promotes a comfortable latch and effective feeding.