Nokea
Which of the following nursing diagnoses is the priority after delivery for a multiparous client who received an epidural anesthetic?
- A. Pain related to episiotomy and exhaustive pushing efforts.
- B. Anxiety related to inability to move legs and toes.
- C. Risk for injury related to epidural anesthesia.
- D. Excess fluid volume overload related to labor process and intravenous fluids.
Correct Answer: C
Rationale: Epidural anesthesia poses a risk for injury due to potential complications like hypotension or impaired mobility, making this the priority post-delivery. Pain, anxiety, and fluid overload are secondary concerns.
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A multigravid laboring client has an extensive documented history of drug addiction. Her last reported usage was 5 hours ago. She is 2 cm dilated with contractions every 3 minutes of moderate intensity. The physician orders nalbuphine (Nubain) 15 mg slow I.V. push for pain relief followed by an epidural when the client is 4 cm dilated. Within 10 minutes of receiving the nalbuphine, the client states she thinks she is going to have her baby now. Of the following drugs available at the time of the delivery, which should the nurse avoid using with this client in this situation?
- A. 1% lidocaine (Xylocaine).
- B. Naloxone hydrochloride (Narcan).
- C. Local anesthetic.
- D. Pudendal block.
Correct Answer: B
Rationale: In a client with recent opioid use, naloxone (Narcan) could precipitate withdrawal symptoms, which is risky during delivery. Lidocaine, local anesthetics, or pudendal blocks are safe for perineal anesthesia and do not interact with the client's history.
The nurse is to assess a newborn for incurving of the trunk. Which illustration indicates the position in which the nurse should place the newborn?
Correct Answer: B
Rationale: To assess for incurving of the trunk, the newborn should be placed in a side-lying position to observe spinal curvature.
One-half hour after vaginal delivery of a term neonate, the nurse palpates the fundus of a primigravid client, noting several large clots and a small trickle of bright red vaginal bleeding. The client's blood pressure is 136/92 mm Hg. Which of the following would the nurse do first?
- A. Continue to monitor the client's fundus every 15 minutes.
- B. Ask the physician for an order for methylergonovine (Methergine).
- C. Immediately notify the physician of the client's symptoms.
- D. Change the client's perineal pads every 15 minutes.
Correct Answer: C
Rationale: Large clots and bright red bleeding post-delivery suggest possible uterine atony or retained placental fragments, requiring immediate physician notification for intervention. Monitoring, requesting medication, or changing pads are secondary actions.
A client asks about the benefits of the hormonal IUD. Which of the following responses by the nurse is accurate?
- A. It can reduce menstrual bleeding over time.
- B. It provides protection against HIV.
- C. It requires replacement every 6 months.
- D. It is not suitable for women with irregular periods.
Correct Answer: A
Rationale: The hormonal IUD can reduce menstrual bleeding over time, often leading to lighter periods or amenorrhea. It does not protect against HIV, lasts 3-7 years, and is suitable for irregular periods.
A 39-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. To ensure cardiac emptying and adequate oxygenation during labor, the nurse plans to encourage the client to do which of the following?
- A. Breathe slowly after each contraction.
- B. Avoid the use of analgesics for the labor pain.
- C. Remain in a side-lying position with the head elevated.
- D. Request local anesthesia for vaginal delivery.
Correct Answer: C
Rationale: For class II heart disease, a side-lying position with head elevation reduces cardiac strain by optimizing venous return and oxygenation. Slow breathing is helpful but less specific, avoiding analgesics may increase stress, and local anesthesia is unrelated to cardiac emptying.