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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. Fever.
- B. Diarrhea.
- C. Sedation.
- D. Diuresis.
Correct Answer: C
Rationale: Sedation is a known adverse effect of nalbuphine hydrochloride as it acts on the central nervous system to relieve pain, which can cause drowsiness.
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Nurses' Notes Two weeks ago (32 weeks gestation): The client presented for a routine visit and denied vaginal bleeding or fluid leakage. Reports mild insomnia and occasional mild uterine cramping. 1+ nonpitting edema noted in bilateral feet and ankles. Weight recorded as 84 kg (185 lb). Today (0930): The client reports mild epigastric pain for the past three days and occasionally 'seeing spots' in her vision. 2+ nonpitting edema noted bilaterally in feet and ankles, and mild facial edema present. The client states her fingers 'swelled up overnight,' preventing her from wearing rings. Weight has increased to 86 kg (190 lb). Vital Signs: Blood pressure: 160/100 mm Hg, Heart rate: 88/min, Respiratory rate: 18/min, Temperature: 36.9°C (98.4°F), Oxygen saturation: 98% on room air. Diagnostic Results: Hemoglobin: 10 g/dL, Hematocrit: 35.9%, Platelet count: 95,000/mm³, AST: 200 U/L, ALT: 25 U/L, Total bilirubin: 1.8 mg/dL, Urine protein: 2+.
Which of the following findings should the nurse report to the primary health care provider?
- A. Platelet count
- B. Hematocrit value
- C. Nonstress test result
- D. Weight gain
- E. Edema
- F. Blood pressure
- G. BUN
Correct Answer: A,D,E,F
Rationale: Low platelets, rapid weight gain, edema, high BP, and proteinuria indicate preeclampsia, requiring immediate reporting.
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. Encourage the client to continue to breastfeed.
- B. Prepare the client for an abdominal sonogram.
- C. Encourage the client to wear a loose-fitting bra.
- D. Limit the client's daily fluid intake.
Correct Answer: A
Rationale: Encouraging the client to continue to breastfeed helps empty the breast, reducing pain and inflammation and promoting healing from mastitis.
Nurses' Notes: The client, who is 28 weeks gestation, gravida 4, para 3, reports a history of vaginal bleeding for the past 2 hours. She states, 'I started bleeding a couple of hours ago, but now I am saturating pads with bright red blood. I’m scared something is going to happen to my baby.' Blood is trickling down her legs. She denies abdominal pain. A perineal pad is saturated with bright red vaginal bleeding. Physical Examination Results: Fundal height is 27 cm. No uterine contractions or irritability. Fetal heart rate: 170/min, minimal variability, no decelerations. Diagnostic Results: Urine: Leukocyte esterase positive, Nitrites positive, Red blood cells: 6.
Complete the diagram by dragging from the choices below to specify: Potential Condition, Actions to Take (Select 2), Parameters to Monitor (Select 2). Potential Condition Choices: A. Placenta previa, B. Abruptio placentae, C. Preterm labor, D. Uterine rupture. Actions: A. Administer methotrexate, B. Administer broad-spectrum antibiotics, C. Prepare for an emergency cesarean birth, D. Reinforce bed rest and maintain IV access, E. Encourage ambulation. Parameters: A. Fetal heart rate, B. Maternal oxygen saturation, C. WBC count, D. Urine output, E. Uterine contractions.
- A. Placenta previa
- B. Prepare for an emergency cesarean birth
- C. Reinforce bed rest and maintain IV access
- D. Fetal heart rate
- E. Maternal oxygen saturation
Correct Answer: A,C,D,A,B
Rationale: Painless bleeding suggests placenta previa; cesarean and bed rest manage it; fetal heart rate and oxygen saturation monitor stability.
A nurse is reinforcing teaching with a client about common discomforts during the first trimester of pregnancy.
Which of the following discomforts should the nurse include in the teaching?
- A. Tingling in the fingers.
- B. Round ligament pain.
- C. Urination urgency and frequency.
- D. Perineal discomfort and pressure.
Correct Answer: C
Rationale: Urination urgency and frequency are common first-trimester discomforts due to hormonal changes and uterine pressure on the bladder.
A nurse is caring for a client who is at 9 weeks of gestation and reports nausea in the morning that continues until midafternoon.
Which of the following actions should the nurse encourage the client to take?
- A. Eat dry, bland foods in the morning.
- B. Take an over-the-counter antacid.
- C. Increase intake of fresh fruits.
- D. Restrict fluids to 1,000 ml/day.
Correct Answer: A
Rationale: Eating dry, bland foods like crackers in the morning can alleviate nausea by absorbing stomach acid, a common remedy for early pregnancy nausea.