a client is in active labor and is receiving an epidural for pain relief which of the following should the nurse monitor as the priority
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Nursing Elites

ATI LPN

PN ATI Capstone Maternal Newborn

1. A client is in active labor and is receiving an epidural for pain relief. Which of the following should the nurse monitor as the priority?

Correct answer: B

Rationale: The most common side effect of an epidural is hypotension, which can compromise placental perfusion. Monitoring the client's blood pressure is the priority to ensure maternal and fetal well-being. Fetal heart rate is important but monitoring the client's blood pressure takes precedence due to the risk of hypotension. Respiratory rate and pain level monitoring are also important but not the priority in this scenario.

2. A nurse is caring for a newborn who has a blood glucose level of 45 mg/dL. Which of the following actions should the nurse take?

Correct answer: A

Rationale: Encouraging the mother to breastfeed the newborn is the most appropriate action in this scenario. Breastfeeding can quickly raise blood glucose levels in newborns. A blood glucose level of 45 mg/dL is often acceptable in newborns, but close monitoring is necessary. Gavage feeding with glucose water or administering D5W via IV may not be necessary at this point and could lead to potential risks of overfeeding or hypoglycemia. Rechecking the glucose level in 2 hours may delay necessary intervention, as breastfeeding can promptly address the low blood glucose levels.

3. A nurse receives a report on four clients. Which client should the nurse assess first?

Correct answer: C

Rationale: The correct answer is C. Low back pain during a blood transfusion is a classic sign of a transfusion reaction, specifically a transfusion-associated circulatory overload (TACO) or hemolytic reaction, both of which require immediate attention to prevent serious complications. Assessing this client first is crucial to ensure prompt intervention. Choices A, B, and D do not indicate immediate life-threatening complications and can be addressed after the client experiencing low back pain during a blood transfusion is stabilized.

4. A client has a stool culture positive for C. difficile. What action should the nurse take?

Correct answer: D

Rationale: When caring for a client with a C. difficile infection, it is essential to isolate them in a private room to prevent the spread of spores through contact with surfaces. Placing the client in a negative pressure room (Choice A) is not necessary for C. difficile. Using alcohol-based hand rub (Choice B) and wearing a face shield (Choice C) are important infection control measures but are not specific to the isolation requirements for C. difficile.

5. A nurse is caring for a client with a prescription for ferrous sulfate. What instruction should the nurse provide?

Correct answer: B

Rationale: The correct instruction for a client prescribed ferrous sulfate is to take it with fluids other than coffee or tea. Coffee and tea can hinder iron absorption, so it's important to take the medication with other types of fluids. Choice A is incorrect because strawberries and citrus fruits are sources of vitamin C, which actually enhance iron absorption. Choice C is incorrect because ferrous sulfate is usually recommended to be taken on an empty stomach for better absorption. Choice D is incorrect as doubling the dose of ferrous sulfate can lead to an overdose and severe side effects.

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