Nursing Elites

1. A client reports unrelieved episiotomy pain 8 hours following a vaginal birth. Which of the following actions should the nurse take?

• A. Apply an ice pack to the affected area.
• B. Offer a warm sitz bath.
• C. Provide a squeeze bottle of antiseptic solution.
• D. Place a hot pack on the perineum.

Correct answer: A

Rationale: The correct answer is to apply an ice pack to the affected area. Ice packs help reduce swelling, inflammation, and provide pain relief post-episiotomy. Applying heat, as in a hot pack or warm sitz bath, can increase swelling and discomfort. Providing antiseptic solution in a squeeze bottle is not the first-line intervention for managing episiotomy pain, as the priority is pain relief and comfort.

2. A client at 8 weeks of gestation with iron deficiency anemia is prescribed iron supplements. Which beverage should the nurse reinforce the client to take the supplements with for better absorption?

• A. Ice water
• B. Low-fat or whole milk
• C. Tea or coffee
• D. Orange juice

Correct answer: D

Rationale: The correct answer is 'Orange juice.' Orange juice is recommended to be taken with iron supplements because vitamin C present in orange juice enhances iron absorption, improving the effectiveness of the supplement. It is essential to take iron supplements with a source of vitamin C to optimize iron absorption and address iron deficiency anemia. Ice water (Choice A), low-fat or whole milk (Choice B), and tea or coffee (Choice C) are not ideal choices to take with iron supplements as they do not contain vitamin C, which is crucial for enhancing iron absorption.

3. A healthcare provider is assisting with the care for a client who has a prescription for magnesium sulfate. The provider should recognize that which of the following are contraindications for the use of this medication? (Select all that apply)

• A. Fetal distress
• B. Cervical dilation greater than 6 cm
• C. Vaginal bleeding
• D. All of the Above

Correct answer: D

Rationale: The correct answer is D, 'All of the Above.' Magnesium sulfate should not be used in cases of fetal distress, vaginal bleeding, or cervical dilation greater than 6 cm. These conditions can be exacerbated by the administration of magnesium sulfate, leading to further complications for the client. Choice A, fetal distress, is a contraindication because magnesium sulfate can further affect the fetal heart rate. Choice B, cervical dilation greater than 6 cm, is a contraindication as magnesium sulfate can potentially suppress uterine contractions, prolonging labor. Choice C, vaginal bleeding, is a contraindication as magnesium sulfate can further increase bleeding tendencies.

4. A full-term newborn is being assessed by a nurse 15 minutes after birth. Which of the following findings requires intervention by the nurse?

• A. Heart rate 168/min
• B. Respiratory rate 18/min
• C. Tremors
• D. Fine crackles

Correct answer: B

Rationale: A newborn's respiratory rate can vary between 20 to 100 breaths per minute during the initial phase after birth. A respiratory rate as low as 18 breaths per minute at this early stage requires immediate nursing intervention. This finding necessitates further assessment to ensure adequate oxygenation and respiratory function. The other options, heart rate of 168/min, tremors, and fine crackles, are within normal limits for a full-term newborn and do not require immediate intervention.

5. A nurse is caring for a client who is at 40 weeks of gestation and is in early labor. The client has a platelet count of 75,000/mm3 and is requesting pain relief. Which of the following treatment modalities should the nurse anticipate?

• A. Epidural analgesia
• B. Naloxone hydrochloride
• C. Attention-focusing
• D. Pudendal nerve block

Correct answer: C

Rationale: Attention-focusing and distraction techniques are types of nonpharmacological care that are effective in relieving labor pain.

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