Nursing Elites

1. Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action should the healthcare provider take?

• A. Notify the healthcare provider or anesthesiologist immediately.
• B. Continue to assess the blood pressure every 5 minutes.
• C. Place the woman in a lateral position.
• D. Turn off the continuous epidural.

Correct answer: C

Rationale: Placing the woman in a lateral position is the appropriate action to improve venous return and cardiac output, helping to stabilize the blood pressure. This position can alleviate pressure on the inferior vena cava, reducing the risk of hypotension associated with epidural anesthesia. Turning off the continuous epidural would not be the initial action as it may not be necessary and could lead to inadequate pain relief for the client. Notifying the healthcare provider or anesthesiologist immediately is premature and should be done after attempting non-invasive interventions. Continuing to assess the blood pressure every 5 minutes is important, but placing the woman in a lateral position should be the first intervention to address the hypotension.

2. When teaching a gravid client how to perform kick (fetal movement) counts, which instruction should the nurse include?

• A. If 10 kicks are not felt within one hour, drink orange juice and count for another hour.
• B. Count the movements once daily, for one hour, before breakfast.
• C. Avoid caffeinated drinks for 24 hours before conducting the kick test.
• D. Exercise for 15 minutes before starting the counting to help increase fetal movement.

Correct answer: A

Rationale: When teaching a gravid client about kick (fetal movement) counts, the nurse should instruct them that if 10 kicks are not felt within one hour, they should drink orange juice and continue counting for another hour. This instruction is crucial as a drop in fetal movements could indicate potential issues with fetal well-being, and taking action such as rechecking after food intake is recommended to monitor the situation closely.

3. The client delivered hours ago and has a boggy uterus displaced above and to the right of the umbilicus. What action should the nurse take?

• A. Inspect the perineal pad.
• B. Encourage voiding.
• C. Monitor vital signs.
• D. Notify the healthcare provider.

Correct answer: B

Rationale: A boggy uterus that is displaced above and to the right of the umbilicus may indicate a full bladder, which can impede uterine contraction and lead to hemorrhage. Encouraging the client to void helps relieve pressure on the uterus, promoting better contraction and preventing postpartum hemorrhage.

4. The healthcare provider notes on the fetal monitor that a laboring client has a variable deceleration. Which action should the healthcare provider implement first?

• A. Assess cervical dilation.
• B. Change the client's position.
• C. Administer oxygen via facemask.
• D. Turn off the oxytocin infusion.

Correct answer: B

Rationale: Changing the client's position is the priority intervention for variable decelerations as it can relieve pressure on the umbilical cord, potentially resolving the deceleration and improving fetal oxygenation. Assessing cervical dilation, administering oxygen via facemask, and turning off the oxytocin infusion are important interventions but addressing the fetal distress caused by variable decelerations takes precedence.

5. The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor. Before initiating this prescription, it is most important for the LPN/LVN to assess the client for which condition?

• A. Gestational diabetes.
• B. Elevated blood pressure.
• C. Urinary tract infection.
• D. Swelling in lower extremities.

Correct answer: A

Rationale: The correct answer is A: Gestational diabetes. Terbutaline (Brethine) is known to cause hyperglycemia, so it is crucial to assess for gestational diabetes before administering it. Assessing for elevated blood pressure (choice B), urinary tract infection (choice C), or swelling in lower extremities (choice D) is not directly related to the potential side effect of terbutaline in causing hyperglycemia.

Similar Questions