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 assessing a newborn with respiratory distress syndrome who received synthetic surfactant, which parameter should the nurse monitor to evaluate the newborn's condition?

• A. Oxygen saturation
• B. Body temperature
• C. Serum bilirubin
• D. Heart rate

Correct answer: A

Rationale: In a newborn with respiratory distress syndrome who has received synthetic surfactant, monitoring oxygen saturation is crucial to evaluate the effectiveness of the treatment. Oxygen saturation levels provide valuable information about the newborn's respiratory status and the adequacy of gas exchange. Changes in oxygen saturation can indicate improvements or deterioration in the newborn's condition following the administration of synthetic surfactant. Monitoring oxygen saturation helps the nurse assess the newborn's response to treatment and make timely interventions if needed. Body temperature, serum bilirubin, and heart rate are important parameters to monitor in newborns for other conditions but are not specific indicators of the effectiveness of synthetic surfactant in treating respiratory distress syndrome.

3. A client is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of letdown after childbirth. Which of the following conditions is associated with these manifestations?

• A. Postpartum fatigue
• B. Postpartum psychosis
• C. Letting-go phase
• D. Postpartum blues

Correct answer: D

Rationale: The correct answer is D, Postpartum blues. Postpartum blues, also known as baby blues, are common after childbirth and are characterized by symptoms like tearfulness, insomnia, lack of appetite, and a feeling of letdown. This condition is typically self-limiting and resolves without specific treatment. Postpartum fatigue (choice A) refers to extreme tiredness after childbirth but does not typically include symptoms like tearfulness and insomnia. Postpartum psychosis (choice B) is a severe condition that includes symptoms such as hallucinations and delusions, which are not present in the scenario. The letting-go phase (choice C) does not represent a specific postpartum condition related to the symptoms described.

4. When calculating the Apgar score of a newborn at 1 minute after delivery, which of the following findings would result in a score of 6?

• A. 4
• B. 5
• C. 6
• D. 7

Correct answer: C

Rationale: The Apgar score is calculated based on five parameters: heart rate, respiratory effort, muscle tone, reflex irritability, and color. In this case, the newborn's findings at 1 minute after delivery indicate a heart rate >100/min (2 points), slow, weak cry (1 point), some flexion of extremities (1 point), grimace in response to suctioning (1 point), and body pink with blue extremities (1 point). Adding these points together results in a total Apgar score of 6, reflecting the newborn's initial assessment for their overall well-being. Choice A (4) is too low based on the given findings, while Choice B (5) is also lower than the correct score of 6. Choice D (7) is too high as it would require additional findings to reach that score.

5. During an assessment of a newborn following a vacuum-assisted delivery, which of the following findings should the healthcare provider be informed about?

• A. Poor sucking
• B. Blue discoloration of the hands and feet
• C. Soft, edematous area on the scalp
• D. Facial edema

Correct answer: A

Rationale: Poor sucking in a newborn following a vacuum-assisted delivery could indicate potential issues with feeding or neurological function, which need to be promptly addressed by the healthcare provider to ensure the well-being of the infant. It is essential for the healthcare provider to be informed about poor sucking to facilitate further evaluation and intervention. Choices B, C, and D are not typically associated with vacuum-assisted delivery and do not pose immediate concerns that require urgent attention.

Similar Questions