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. The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take?

• A. Administer oxygen by face mask.
• B. Notify the healthcare provider of the client's symptoms.
• C. Have the client breathe into her cupped hands.
• D. Check the client's blood pressure and fetal heart rate.

Correct answer: C

Rationale: Tingling fingers and dizziness are symptoms of hyperventilation, which can occur with accelerated-blow breathing. Instructing the client to breathe into her cupped hands can help rebreathe exhaled carbon dioxide, which can alleviate the symptoms by restoring the proper balance of oxygen and carbon dioxide in the blood. This intervention can be effective in managing the client's hyperventilation without the need for additional medical interventions at this point.

3. The healthcare provider is assessing a 2-hour-old infant born by cesarean delivery at 39-weeks gestation. Which assessment finding should receive the highest priority when planning the infant’s care?

• A. Blood pressure 76/42 mmHg.
• B. Faint heart murmur.
• C. Respiratory rate of 76 breaths/minute.
• D. Blood glucose 45 mg/dl.

Correct answer: C

Rationale: A high respiratory rate in a newborn is concerning as it may indicate respiratory distress, which requires immediate attention to ensure adequate oxygenation. Monitoring and addressing respiratory issues take precedence over other parameters in the initial assessment of a newborn. The blood pressure, heart murmur, and blood glucose levels are important but not as urgent as addressing potential respiratory distress in a newborn.

4. A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first?

• A. Suction the oral and nasal passages.
• B. Give oxygen by positive pressure.
• C. Stimulate the infant to cry.
• D. Turn the infant onto the right side.

Correct answer: A

Rationale: In a situation where an infant regurgitates and turns cyanotic, the priority action should be to clear any potential airway obstruction. Suctioning the oral and nasal passages is crucial to ensure the infant's airway is clear and allow for proper breathing. This intervention takes precedence over providing oxygen, stimulating the infant to cry, or repositioning the infant.

5. At 35 weeks gestation, a client complains of 'pain whenever the baby moves.' The nurse notes a temperature of 101.2 F (38.4 C) with severe abdominal or uterine tenderness on palpation. What condition do these findings indicate?

• A. Round ligament strain.
• B. Chorioamnionitis.
• C. Abruptio placentae.
• D. Viral infection.

Correct answer: B

Rationale: The client's symptoms of fever and abdominal tenderness, along with the gestational age, are classic signs of chorioamnionitis, an infection of the amniotic fluid. Chorioamnionitis is a serious condition that requires prompt recognition and treatment to prevent maternal and fetal complications. Round ligament strain (Choice A) typically presents with sharp, stabbing pain on the sides of the abdomen and is not associated with fever or uterine tenderness. Abruptio placentae (Choice C) presents with sudden-onset vaginal bleeding and severe abdominal pain, often with a board-like uterus. Viral infections (Choice D) may present with a variety of symptoms, but the combination of fever, abdominal tenderness, and gestational age in this scenario points more towards chorioamnionitis.

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