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 educating a pregnant client about potential complications, which manifestation should the nurse emphasize reporting to the provider promptly?

• A. Vaginal bleeding
• B. Swelling of the ankles
• C. Heartburn after eating
• D. Lightheadedness when lying on back

Correct answer: A

Rationale: Vaginal bleeding during pregnancy is a concerning sign that could indicate serious complications like miscarriage or placental issues. Prompt reporting to the healthcare provider is crucial for timely evaluation and management to ensure the best outcomes for both the mother and the baby. Swelling of the ankles (choice B), heartburn after eating (choice C), and lightheadedness when lying on the back (choice D) are common discomforts during pregnancy but are not typically associated with serious complications that require immediate attention.

3. A nurse is admitting a term newborn following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow. This finding indicates the newborn is experiencing a complication related to which of the following?

• A. Maternal/newborn blood group incompatibility
• B. Absence of vitamin K
• C. Physiologic jaundice
• D. Maternal cocaine abuse

Correct answer: A

Rationale: The yellow skin observed in the newborn suggests jaundice. Maternal/newborn blood group incompatibility is a common cause of jaundice in newborns. This occurs when the mother and baby have different blood types, leading to the baby's immune system attacking the red blood cells, causing jaundice. Physiologic jaundice, which is a normal process due to the breakdown of red blood cells in newborns, typically presents after the first 24 hours of life. Absence of vitamin K leads to bleeding issues, not jaundice. Maternal cocaine abuse does not directly cause jaundice in newborns.

4. A client who is at 10 weeks of gestation reports abdominal pain and moderate vaginal bleeding, with a tentative diagnosis of inevitable abortion. Which of the following nursing interventions should be included in the plan of care?

• A. Administer oxygen via nasal cannula.
• B. Offer the option to view products of conception.
• C. Instruct the client to increase potassium-rich foods in the diet.
• D. Maintain the client on bed rest.

Correct answer: B

Rationale: In cases of inevitable abortion, offering the option to view products of conception can assist in emotional healing and closure for the client. This can provide a sense of acknowledgment and closure for the loss experienced, aiding in the grieving process. Administering oxygen via nasal cannula (choice A) is not directly related to the emotional and psychological support needed during an inevitable abortion. Instructing the client to increase potassium-rich foods (choice C) may not be a priority in this situation. Maintaining the client on bed rest (choice D) may be indicated in some cases but does not address the emotional aspect of the situation.

5. A client who is at 22 weeks of gestation reports concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take?

• A. Tell the client to follow up with a dermatologist.
• B. Explain to the client this is an expected occurrence.
• C. Instruct the client to increase her intake of vitamin D.
• D. Inform the client she might have an allergy to her skin care products.

Correct answer: B

Rationale: Chloasma, also known as the mask of pregnancy, is a blotchy, brown hyperpigmentation of the skin over the cheeks, nose, and forehead. It is most common in dark-skinned women and is caused by an increase in melanotropin during pregnancy. This condition typically appears after 16 weeks of gestation and gradually increases until delivery for 50 to 70% of women. The nurse should reassure the client that this is an expected occurrence, which usually fades after delivery. Therefore, explaining to the client that this is an expected occurrence is the appropriate action in this situation. Options A, C, and D are incorrect because chloasma is a common skin change during pregnancy and does not require a referral to a dermatologist, an increase in vitamin D intake, or suspicion of an allergy to skin care products.

Similar Questions