55 Questions
What is a contraindication for Methergine administration?
Observing for an asymmetrical Moro (startle) reflex
What assessment finding suggests the need to question the prescription of Methergine?
Client's blood pressure is 156/96
Why should the LPN/LVN question the prescription of Methergine for the client?
Because Methergine is contraindicated for elevated blood pressure
In which client scenario should a nurse take caution when administering an enema?
Client with elevated blood pressure
What would be a concerning assessment finding for a client receiving an epidural infusion of a narcotic after a cesarean section?
Respiratory rate 8 rpm
What is an appropriate nursing response to a client who has not had a bowel movement 2 days post-cesarean section?
"That is very concerning. I will request that your physician order an enema for you."
Why is it important for the nurse to assess the client's bowel movement post-cesarean section?
To monitor for signs of infection
What could be a potential cause of constipation in a post-cesarean section client?
Antibiotic use
Why is it important for the nurse to monitor the respiratory rate of a client receiving narcotic infusion?
To identify respiratory depression
What is the rationale behind encouraging fluids and exercise for combating constipation post-surgery?
To promote bowel motility
What must a client advised to refrain from consuming while taking Paxil (paroxetine) for postpartum depression?
Alcohol
In a 1 day-postpartum client with perineal pain after receiving ibuprofen, what is an appropriate conclusion for the nurse to make?
She should be assessed by her doctor.
When diagnosed with mastitis, what is an appropriate nursing intervention for a breastfeeding mother?
Encourage the woman to breastfeed frequently.
What is the appropriate action if a client complains of perineal pain at level 9 after receiving ibuprofen for postpartum discomfort?
Consult her doctor
To prevent a drug/food interaction, what should a client avoid when taking medication for postpartum depression?
Alcohol
What should be done if a client has unresolved perineal pain after taking ibuprofen?
Seek assessment from the doctor
What is the most appropriate nursing action for a client experiencing extreme discomfort with the urge to bear down?
Encourage pushing with each contraction
Following a traumatic delivery, a newborn receives an initial Apgar score of 3. What is the most important intervention for the nurse to implement?
Continue resuscitative efforts
What should a nurse do for a 3-hour-old infant with cyanotic hands and feet, an axillary temperature of 96.5 degrees Fahrenheit, a respiratory rate of 40 breaths per minute, and a heart rate of 165 beats per minute?
Gradually warm the infant under a radiant heat source
In what way should a nurse ensure adequate installation of ophthalmic erythromycin 5% ointment into a newborn's eyes?
Instill a thin ribbon into each lower conjunctival sac
What is the initial action a nurse should take upon observing variable deceleration on a fetal monitor in a laboring client?
Change the client's position
After delivering an infant, if a multiparous client's uterine tone remains boggy, what information should the nurse provide about this finding?
Educate on potential postpartum hemorrhage
What is the primary affected gender in Duchenne muscular dystrophy?
Males in the family
Which protein deficiency is associated with Duchenne muscular dystrophy?
Dystrophin
Why should the nurse notify the healthcare provider about an increase in respiratory rate and heart rate post-operatively?
To ensure timely medical intervention if needed
What should a nurse suggest to a woman who is recommended to take medicine along with ginger ale?
Chamomile tea
After a normal spontaneous vaginal delivery, what hemoglobin (Hgb) and hematocrit (Hct) values would the nurse expect to see 2 days post-delivery?
Hgb 11.0 gm/dL; Hct 33%
Which intervention would be appropriate for a G1P1001 woman with postpartum hemorrhoids following vaginal delivery?
The client should apply warm compresses as a relief measure.
What measure would NOT be appropriate for a woman with postpartum hemorrhoids?
Breastfeeding frequently to stimulate oxytocin to reduce hemorrhoid size.
What advice would be incorrect for a woman experiencing postpartum hemorrhoids?
Breastfeeding frequently to stimulate oxytocin to reduce hemorrhoid size.
Which information about postpartum hemorrhoids is inaccurate for a woman to receive during health teaching?
'Using a sitz bath daily can help relieve discomfort.
What is the priority nursing action during the immediate postpartum period?
Palpate fundus
In the immediate postpartum period, a woman is shaking uncontrollably. What is the most appropriate nursing action?
Provide the woman with warm blankets
For a postpartum client with the nursing diagnosis of 'Risk for intrauterine infection,' which of the following goals should be included in the care plan?
The client will have normal temperature
After delivering an infant, if a multiparous client's uterine tone remains boggy, what information should the nurse provide about this finding?
It suggests a potential risk for postpartum hemorrhage
What is a common nursing intervention for a breastfeeding mother diagnosed with mastitis?
Continue breastfeeding and ensure proper emptying of the affected breast
Which action is vital for a nurse to take upon observing variable deceleration on a fetal monitor in a laboring client?
Change the laboring client's position to alleviate pressure on the uterus
What should the nurse do if the client is not having contractions, the fetal heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are occurring?
Notify the healthcare provider of the nonreactive results
What further assessment should the nurse perform if crepitus is identified when examining the chest of a newborn delivered vaginally?
Observe for an asymmetrical Moro (startle) reflex
When a mother brings her 8-month-old baby boy to the clinic due to vomiting and diarrhea for the last 3 days, what is the most important assessment for the nurse to make?
Measure the infant's pulse
What is the most appropriate advice for a woman experiencing tender, hard nodules in her breasts while breastfeeding?
Gently massage the areas toward the nipple especially during feedings.
While obtaining vital signs for a 10-year-old who had a tonsillectomy, if the nurse observes the child swallowing every 2-3 minutes, what assessment should be implemented?
Inspect the posterior oropharynx
Which complication should a nurse monitor a postoperative cesarean client with spinal anesthesia for more closely than an epidural client?
Postural headache.
What action should a nurse take if a 1-day-postpartum client continues to experience perineal pain after receiving ibuprofen?
Encourage ambulation and sitz baths
In the context of postpartum psychosis, what sign/symptom would a woman exhibit?
Hallucinations.
What is crucial for a nurse to do if an 8-month-old infant presents with vomiting and diarrhea?
Evaluate hydration status
What signifies the effectiveness of Methergine (methylergonovine) administration in a postpartum woman?
Fundus firm at the umbilicus.
What advice should a nurse provide to a breastfeeding woman experiencing clogged milk ducts?
Frequent breastfeeding or pumping on the affected side.
Which symptom would be least likely observed in a woman experiencing postpartum psychosis?
Weepy sadness.
What is a necessary step in the plan of care for a newborn whose mother tested positive for hepatitis B surface antigen (HBsAg)?
Administering hepatitis B immune globulin at birth.
Which action should be taken during the hospitalization of a newborn with a mother positive for hepatitis B surface antigen (HBsAg)?
Using universal precautions for the mother and infant.
What statement made by a pregnant woman with asthma indicates a need for further education?
"Bronchodilators can be used whenever I feel short of breath."
Why is it important for a pregnant woman with controlled asthma to continue taking her medication?
To prevent worsening of her asthma symptoms.
What is a key aspect of managing asthma during pregnancy?
Preventing or limiting asthma attacks through proper medication use.
What is a potential risk if a pregnant woman with asthma does not manage her condition effectively?
Reduced fetal growth and oxygen deprivation to the fetus.
Study Notes
Maternal-Newborn Nursing
- A client who is shivering and has an urge to bear down should be encouraged to push with each contraction.
Fetal Monitoring
- A variable deceleration on a fetal monitor strip indicates the need to change the client's position.
Newborn Care
- A 3-hour-old infant with cyanotic hands and feet, an axillary temperature of 96.5°F (35.8°C), a respiratory rate of 40 breaths/minute, and a heart rate of 165 beats/minute should be gradually warmed under a radiant heat source.
- Ophthalmic erythromycin 5% ointment should be instilled in a thin ribbon into each lower conjunctival sac for newborns.
Postpartum Care
- The priority nursing action during the immediate postpartum period is to palpate the fundus.
- A woman experiencing shivering and discomfort after delivery should be provided with warm blankets.
- A client with a boggy fundus 15 minutes after delivery should be advised to apply topical anesthetic as a relief measure.
- A client at risk for intrauterine infection should have goals of drinking sufficient fluids, having a stable white blood cell count, a normal temperature, and normal-smelling vaginal discharge.
Pediatric Nursing
- A 2-week-old infant with an umbilical hernia repair should have increased respiratory and heart rates monitored, and the nurse should notify the healthcare provider of these findings.
- A child with Duchenne muscular dystrophy has an inherited X-linked recessive disorder that primarily affects male children in the family.
Pharmacological Interventions
- A breastfeeding mother taking Paxil (paroxetine) for postpartum depression should be advised to avoid consuming alcohol to prevent drug/food interactions.
- Methergine 0.2 mg IM should not be given to clients with elevated blood pressure.
Breastfeeding
- A breastfeeding mother with mastitis should be encouraged to breastfeed frequently.
- A breastfeeding mother taking a narcotic analgesic should take the medicine with orange juice.
Client Education
- A client with hemorrhoids should be advised to use a sitz bath daily as a relief measure.
- A client with asthma during pregnancy should continue taking asthma medication as prescribed and consistently.
Test your knowledge on assessing a client receiving an epidural infusion of a narcotic for pain relief after cesarean section. Identify which assessments would warrant reporting to the anesthesiologist.
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