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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. Diuresis
- B. Fever
- C. Diarrhea
- D. Sedation
Correct Answer: D
Rationale: Nalbuphine hydrochloride is an opioid analgesic used for pain relief during labor. Sedation is a common adverse effect of opioid medications, including nalbuphine, due to central nervous system depression, leading to drowsiness and decreased consciousness.
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A nurse is reinforcing teaching with a client who is at 10 weeks of gestation regarding the purposes of laboratory tests.
Which of the following statements by the client indicates an understanding of the teaching?
- A. White blood cell count is an indicator of anemia.
- B. Urine specific gravity identifies my risk for pregnancy induced hypertension
- C. Platelet count identifies if I am at risk for bleeding
- D. Sedimentation rate checks for signs of cancer
Correct Answer: C
Rationale: Platelet count identifies bleeding risk by assessing clotting ability, a key concern in pregnancy, showing the client understands the test's purpose accurately.
A nurse is reinforcing discharge teaching about home safety with a client who is postpartum. In which of the following positions should the nurse instruct the client to place their newborn in the crib?
- A. Supine
- B. Prone
- C. Left lateral
- D. Right lateral
Correct Answer: A
Rationale: Placing the newborn supine reduces the risk of sudden infant death syndrome (SIDS), ensuring optimal airway patency and safety during sleep.
A nurse is reinforcing discharge instructions about breastfeeding with a client. Which of the following statements should the nurse make?
- A. You should recognize that your baby sucking on his hands is a hunger cue.
- B. You should feed your baby for 10 minutes on each breast.
- C. You should feed your baby six times a day.
- D. You should wake your baby at least every 6 hours at night for feedings.
Correct Answer: A
Rationale: Recognizing that sucking on hands is a hunger cue helps ensure timely feeding, supporting a successful breastfeeding routine and adequate nutrition for the baby.
A nurse is contributing to the plan of care for a client who is postpartum and has mastitis.
Which of the following actions should the nurse plan to take?
- A. Prepare the client for an abdominal sonogram.
- B. Encourage the client to continue to breastfeed
- C. Encourage the client to wear a bra that is loose fitting
- D. Limit the client's daily fluid intake.
Correct Answer: B
Rationale: Continuing to breastfeed is recommended for clients with mastitis. Breastfeeding helps to drain the breast and can speed up recovery. It also helps to prevent complications such as breast abscess and supports continued milk production.
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.