Nursing Elites

1. A client in labor requests epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?

• A. Position the client supine for 30 minutes after the first dose of anesthetic solution.
• B. Administer 1,000 mL of dextrose 5% in water after the first dose of anesthetic solution.
• C. Monitor the client's blood pressure every 5 minutes after the first dose of anesthetic solution.
• D. Ensure the client has been NPO for 4 hours before the placement of the epidural and the first dose of anesthetic solution.

Correct answer: C

Rationale: The correct action is to monitor the client's blood pressure every 5 to 10 minutes following the first dose of anesthetic solution to assess for maternal hypotension. This is crucial to detect and manage potential complications associated with the epidural anesthesia. Positioning the client supine for a prolonged period can lead to hypotension; administering dextrose solution is not a standard practice in epidural anesthesia; ensuring NPO status for 4 hours is not necessary before epidural placement.

2. When caring for a client receiving nifedipine for prevention of preterm labor, the nurse should monitor the client for which of the following manifestations?

• A. Blood-tinged sputum
• B. Dizziness
• C. Pallor
• D. Somnolence

Correct answer: B

Rationale: Corrected Question: When caring for a client receiving nifedipine for prevention of preterm labor, the nurse should monitor the client for which of the following manifestations? Rationale: Nifedipine, a calcium channel blocker, causes vasodilation, potentially leading to a decrease in blood pressure and side effects such as dizziness. Monitoring for dizziness is essential to ensure the client's safety and well-being during treatment. Choices A, C, and D are incorrect as they are not typically associated with nifedipine use for preventing preterm labor. Blood-tinged sputum may indicate other conditions like pulmonary issues, pallor could suggest anemia or circulatory problems, and somnolence is not a common side effect of nifedipine.

3. During active labor, a nurse notes tachycardia on the external fetal monitor tracing. Which of the following conditions should the nurse identify as a potential cause of the heart rate?

• A. Maternal fever
• B. Fetal heart failure
• C. Maternal hypoglycemia
• D. Fetal head compression

Correct answer: A

Rationale: Maternal fever can lead to fetal tachycardia due to the transmission of maternal fever to the fetus. This can result in an increased fetal heart rate, making it the correct potential cause in this scenario. Fetal heart failure (choice B) would typically present with bradycardia rather than tachycardia, making it an incorrect choice. Maternal hypoglycemia (choice C) is more likely to cause fetal distress rather than tachycardia. Fetal head compression (choice D) may lead to decelerations in the fetal heart rate pattern, but not necessarily tachycardia.

4. A client at 40 weeks of gestation is experiencing contractions every 3 to 5 minutes, becoming stronger. A vaginal exam by the registered nurse reveals the client's cervix is 3 cm dilated, 80% effaced, and -1 station. The client requests pain medication. Which of the following actions should the nurse prepare to take? (Select all that apply)

• A. Provide ice chips.
• B. Insert an indwelling urinary catheter.
• C. Administer opioid analgesic medication.
• D. Provide ice chips.

Correct answer: C

Rationale: During labor, effective pain management is crucial. The nurse should assist the client with patterned breathing techniques to help manage pain and administer opioid analgesic medication as ordered. Providing ice chips is a comfort measure but does not directly address pain relief. Inserting a urinary catheter is not typically indicated at this stage of labor unless there are specific medical indications, such as the need to closely monitor urine output. Therefore, the correct action for the nurse to prepare to take in this scenario is to administer opioid analgesic medication.

5. During a nonstress test for a pregnant client, a nurse uses an acoustic vibration device. The client inquires about its purpose. Which response should the nurse provide?

• A. It is used to stimulate uterine contractions.
• B. It will decrease the incidence of uterine contractions.
• C. It lulls the fetus to sleep.
• D. It awakens a sleeping fetus.

Correct answer: D

Rationale: The acoustic vibration device is utilized during a nonstress test to awaken a sleeping fetus. This action helps ensure more accurate test results by eliciting fetal movements and heart rate accelerations, which are indicators of fetal well-being. Choices A, B, and C are incorrect because the primary purpose of the acoustic vibration device during a nonstress test is not to stimulate uterine contractions, decrease uterine contractions, or lull the fetus to sleep. Instead, it is specifically used to awaken a sleeping fetus to assess fetal well-being.

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