Nokea
Which of the following should be the nurse's priority assessment after an epidural anesthetic has been administered to a client in labor?
- A. Level of consciousness.
- B. Blood pressure.
- C. Cognitive function.
- D. Contraction pattern.
Correct Answer: B
Rationale: Epidurals can cause hypotension due to vasodilation, making blood pressure the priority assessment.
You may also like to solve these questions
Betamethasone (Celestone) syrup 0.9 mg has been ordered. It is available in a 0.6 mg/5 mL solution. How many milliliters should the nurse administer?
- A. 5 mL
- B. 7.5 mL
- C. 10 mL
- D. 2.5 mL
Correct Answer: B
Rationale: To calculate: (0.9 mg / 0.6 mg) × 5 mL = 7.5 mL.
The nurse is working on a birthing unit that has several unlicensed assistive personnel (UAP). The nurse determines that the UAP understands the type of information to report to the nurse when the UAP reports which of the following about one of the clients?
- A. An episode of nausea after administration of an epidural anesthetic.
- B. Contractions 3 minutes apart and lasting 40 seconds.
- C. Scream of spontaneous rupture of the membranes.
- D. Sleeping after administration of I.V. nalbuphine (Nubain).
Correct Answer: A,C
Rationale: Nausea after an epidural and spontaneous rupture of membranes are significant events requiring nurse assessment due to potential complications. Contractions and sleeping are expected findings.
The nurse is assessing a neonate at 5 minutes after birth. The nurse records the Apgar score based on the findings in the chart below. The nurse compares these findings to the Apgar score obtained at birth, as determined by the findings in the chart below. What should the nurse do next?
- A. Notify the neonatologist on call.
- B. Continue to assess the neonate.
- C. Apply an oxygen mask.
- D. Rub the neonate's extremities.
Correct Answer: B
Rationale: Without specific Apgar score data, the standard action is to continue assessing the neonate, as Apgar scores at 5 minutes guide ongoing monitoring unless critical findings are present.
Which of the following is an adverse effect of vancomycin (Vancocin) and needs to be reported promptly?
- A. Vertigo.
- B. Tinnitus.
- C. Muscle stiffness.
- D. Ataxia.
Correct Answer: B
Rationale: Tinnitus is a sign of ototoxicity, a serious adverse effect of vancomycin that requires prompt reporting to prevent permanent hearing damage.
The nurse is caring for a client who has just undergone a tonsillectomy. Which of the following interventions is most important in the immediate postoperative period?
- A. Encourage frequent swallowing.
- B. Monitor for excessive swallowing.
- C. Offer ice chips immediately.
- D. Keep the head of the bed flat.
Correct Answer: B
Rationale: Monitoring for excessive swallowing is critical post-tonsillectomy, as it may indicate bleeding from the surgical site.