Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has had a pudendal nerve block. The nurse should monitor which of the following findings has an adverse effect.
A. Fetal bradycardia.
Fetal bradycardia is not a common adverse effect of a pudendal nerve block. This block primarily affects the mother’s pelvic region and does not typically impact fetal heart rate.
B. Decreased ability to bear down.
Decreased ability to bear down is correct because the pudendal nerve block can numb the perineal area, reducing the mother’s ability to feel contractions and effectively bear down during labor.
C. Maternal hypertension.
Maternal hypertension is not associated with pudendal nerve blocks. This block is localized and does not generally affect systemic blood pressure.
D. Uterine hyperstimulation.
Uterine hyperstimulation is not a known adverse effect of pudendal nerve blocks. This condition is more commonly associated with the use of labor-inducing drugs like oxytocin.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Maternal Newborn 2019 NGN Proctored Exam. Take the full exam now
Full Explanation
The correct answer is choice B. Decreased ability to bear down.
Choice A rationale:
Fetal bradycardia is not a common adverse effect of a pudendal nerve block. This block primarily affects the mother’s pelvic region and does not typically impact fetal heart rate.
Choice B rationale:
Decreased ability to bear down is correct because the pudendal nerve block can numb the perineal area, reducing the mother’s ability to feel contractions and effectively bear down during labor.
Choice C rationale:
Maternal hypertension is not associated with pudendal nerve blocks. This block is localized and does not generally affect systemic blood pressure.
Choice D rationale:
Uterine hyperstimulation is not a known adverse effect of pudendal nerve blocks. This condition is more commonly associated with the use of labor-inducing drugs like oxytocin.
Similar Questions
A nurse is providing teaching to a client who reports that her baby has yellow discharge forming at the circumcision site. Which of the following is an appropriate response by the nurse?
A. "I will need to obtain a sample of the discharge for laboratory testing.".
The nurse does not need to obtain a sample of the discharge for laboratory testing at this point. Yellow discharge after circumcision is common and generally not a cause for immediate concern. Laboratory testing is not necessary for routine circumcision care.
B. "Apply povidone-iodine solution twice daily to the circumcision site.".
Applying povidone-iodine solution twice daily to the circumcision site is not recommended in this situation. Povidone-iodine may cause irritation and delay the natural healing process. Generally, no specific cleaning solution is required for circumcision care unless otherwise indicated by a healthcare provider.
C. "Wipe the discharge away gently with a washcloth and warm water for the next 48 hours.".
Wiping the discharge away gently with a washcloth and warm water for the next 48 hours is not the most appropriate action. The circumcision site should be kept clean and dry, but actively wiping away the discharge may cause irritation and disrupt the natural healing process.
D. "The discharge is common during the first 24 to 72 hours following a circumcision.".
The discharge is common during the first 24 to 72 hours following a circumcision
Full Explanation
Choice A rationale:
The nurse does not need to obtain a sample of the discharge for laboratory testing at this point. Yellow discharge after circumcision is common and generally not a cause for immediate concern. Laboratory testing is not necessary for routine circumcision care.
Choice B rationale:
Applying povidone-iodine solution twice daily to the circumcision site is not recommended in this situation. Povidone-iodine may cause irritation and delay the natural healing process.
Generally, no specific cleaning solution is required for circumcision care unless otherwise indicated by a healthcare provider.
Choice C rationale:
Wiping the discharge away gently with a washcloth and warm water for the next 48 hours is not the most appropriate action. The circumcision site should be kept clean and dry, but actively wiping away the discharge may cause irritation and disrupt the natural healing process.
A nurse is providing teaching to a client about the purpose of her upcoming indirect Coombs' test. Which of the following statements should the nurse include in the teaching?
A. "This test determines if your baby is at risk for developing hypoglycemia after birth.".
This statement is incorrect. An indirect Coombs' test is not used to determine the risk of hypoglycemia in a baby after birth. It is used to detect antibodies against red blood cells, particularly in the context of blood incompatibility between a pregnant woman and her fetus.
B. "This test will determine the amount of amniotic fluid around the fetus.".
This statement is incorrect. An indirect Coombs' test is not related to determining the amount of amniotic fluid around the fetus. It is used primarily to assess for Rh incompatibility between the mother and fetus.
C. "This test studies blood flow in the fetus and placenta using ultrasound waves.".
This statement is incorrect. The test described here is a Doppler ultrasound, not an indirect Coombs' test. Doppler ultrasound is used to study blood flow in the fetus and placenta using ultrasound waves.
D. "This test will detect the presence of Rh-positive antibodies in your blood."
This test will detect the presence of Rh-positive antibodies in your blood.
Full Explanation
Choice A rationale:
This statement is incorrect. An indirect Coombs' test is not used to determine the risk of hypoglycemia in a baby after birth. It is used to detect antibodies against red blood cells, particularly in the context of blood incompatibility between a pregnant woman and her fetus.
Choice B rationale:
This statement is incorrect. An indirect Coombs' test is not related to determining the amount of amniotic fluid around the fetus. It is used primarily to assess for Rh incompatibility between the mother and fetus.
Choice C rationale:
This statement is incorrect. The test described here is a Doppler ultrasound, not an indirect Coombs' test. Doppler ultrasound is used to study blood flow in the fetus and placenta using ultrasound waves.
A nurse is caring for a client who is at 30 weeks of gestation and is receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations as an adverse reaction to the medication?
A. Urine output 20 mL/hr.
This manifestation, urine output of 20 mL/hr, is an adverse reaction to magnesium sulfate administration. Magnesium sulfate can lead to decreased urine output, and it is essential for the nurse to monitor the client's urinary output closely. Low urine output may indicate decreased kidney function, which can be a sign of magnesium toxicity.
B. Hypertension.
Hypertension is expected in a client with preeclampsia, and magnesium sulfate is used to help manage and prevent seizures in these cases. While it is essential to monitor and manage hypertension during pregnancy, it is not considered an adverse reaction to magnesium sulfate.
C. Hyperglycemia.
Hyperglycemia is not a common adverse reaction to magnesium sulfate. Magnesium sulfate may cause central nervous system depression, muscle weakness, and respiratory depression, but it does not typically cause hyperglycemia.
D. Respiratory rate 16/min.
A respiratory rate of 16/min is within the normal range for an adult and is not indicative of an adverse reaction to magnesium sulfate. Magnesium sulfate can cause respiratory depression at higher doses, but a respiratory rate of 16/min does not raise immediate concerns.
Full Explanation
Choice A rationale:
This manifestation, urine output of 20 mL/hr, is an adverse reaction to magnesium sulfate administration. Magnesium sulfate can lead to decreased urine output, and it is essential for the nurse to monitor the client's urinary output closely. Low urine output may indicate decreased kidney function, which can be a sign of magnesium toxicity.
Choice B rationale:
Hypertension is expected in a client with preeclampsia, and magnesium sulfate is used to help manage and prevent seizures in these cases. While it is essential to monitor and manage hypertension during pregnancy, it is not considered an adverse reaction to magnesium sulfate.
Choice C rationale:
Hyperglycemia is not a common adverse reaction to magnesium sulfate. Magnesium sulfate may cause central nervous system depression, muscle weakness, and respiratory depression, but it does not typically cause hyperglycemia.
Choice D rationale:
A respiratory rate of 16/min is within the normal range for an adult and is not indicative of an adverse reaction to magnesium sulfate. Magnesium sulfate can cause respiratory depression at higher doses, but a respiratory rate of 16/min does not raise immediate concerns.