Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has maternal hypotension following the placement of an epidural. Which of the following actions should the nurse take?
A. Position the client in a knee-chest position.
Positioning the client in a knee-chest position is not the standard intervention for maternal hypotension following epidural placement. This position is more commonly associated with cord prolapse or to relieve pressure on the vena cava.
B. Administer a bolus infusion of lactated Ringer's.
Administering a bolus infusion of lactated Ringer’s is the correct action. Hypotension during epidural analgesia is treated with additional intravenous boluses of crystalloid solution. This helps to increase the circulating blood volume and counteract the vasodilation caused by the epidural.
C. Give terbutaline subcutaneously.
Terbutaline is a medication used to relax the uterus and prevent premature labor, not for treating hypotension.
D. Apply oxygen via a nonrebreather face mask at 2 L/min.
Applying oxygen via a nonrebreather face mask at 2 L/min is not the primary treatment for maternal hypotension. Oxygen may be used as a supportive measure if there is evidence of fetal distress or maternal hypoxemia, but the first line of treatment for hypotension is fluid administration.
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: Administer a bolus infusion of lactated Ringer’s.
Choice A rationale:
Positioning the client in a knee-chest position is not the standard intervention for maternal hypotension following epidural placement. This position is more commonly associated with cord prolapse or to relieve pressure on the vena cava.
Choice B rationale:
Administering a bolus infusion of lactated Ringer’s is the correct action. Hypotension during epidural analgesia is treated with additional intravenous boluses of crystalloid solution. This helps to increase the circulating blood volume and counteract the vasodilation caused by the epidural.
Choice C rationale:
Terbutaline is a medication used to relax the uterus and prevent premature labor, not for treating hypotension.
Choice D rationale:
Applying oxygen via a nonrebreather face mask at 2 L/min is not the primary treatment for maternal hypotension. Oxygen may be used as a supportive measure if there is evidence of fetal distress or maternal hypoxemia, but the first line of treatment for hypotension is fluid administration.
Similar Questions
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?
A. Administer broad-spectrum antibiotics.
Administering broad-spectrum antibiotics is crucial for a newborn with a myelomeningocele that is leaking cerebrospinal fluid to prevent infection. The leaking of cerebrospinal fluid can increase the risk of meningitis, which is an infection of the membranes covering the brain and spinal cord. Broad-spectrum antibiotics are used as a prophylactic measure to reduce this risk.
B. Monitor the rectal temperature every 4 hr.
Monitoring the rectal temperature every 4 hours is important for detecting fever, which could indicate infection. However, it is not the most immediate action required for a newborn with a leaking myelomeningocele. The priority is to prevent infection through the administration of antibiotics.
C. Cleanse the site with povidone-iodine.
Cleansing the site with povidone-iodine is not recommended for a myelomeningocele because it can be toxic to the exposed neural tissue. Instead, the area should be covered with a sterile saline dressing to protect the site and prevent drying and further damage to the neural tissue.
D. Prepare for surgical closure after 72 hr.
While surgical closure is necessary for a newborn with myelomeningocele, it is typically performed within 24 to 48 hours after birth, not after 72 hours. Early closure is essential to reduce the risk of infection and further damage to the exposed spinal cord and nerves.
Full Explanation
The correct answer is choice A, administer broad-spectrum antibiotics.
Choice A rationale:
Administering broad-spectrum antibiotics is crucial for a newborn with a myelomeningocele that is leaking cerebrospinal fluid to prevent infection. The leaking of cerebrospinal fluid can increase the risk of meningitis, which is an infection of the membranes covering the brain and spinal cord. Broad-spectrum antibiotics are used as a prophylactic measure to reduce this risk.
Choice B rationale:
Monitoring the rectal temperature every 4 hours is important for detecting fever, which could indicate infection. However, it is not the most immediate action required for a newborn with a leaking myelomeningocele. The priority is to prevent infection through the administration of antibiotics.
Choice C rationale:
Cleansing the site with povidone-iodine is not recommended for a myelomeningocele because it can be toxic to the exposed neural tissue. Instead, the area should be covered with a sterile saline dressing to protect the site and prevent drying and further damage to the neural tissue.
Choice D rationale:
While surgical closure is necessary for a newborn with myelomeningocele, it is typically performed within 24 to 48 hours after birth, not after 72 hours. Early closure is essential to reduce the risk of infection and further damage to the exposed spinal cord and nerves.
A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical findings should the nurse expect?
A. Telangiectatic nevi.
Telangiectatic nevi are commonly known as "stork bites”. or "angel kisses”. and are superficial vascular areas commonly found on the nape of the neck or the eyelids of newborns. These are benign and pose no significant health risks.
B. Erythema toxicum.
Erythema toxicum is a common, benign skin rash that appears in the first few days of life. It presents as small, raised red spots with a surrounding halo and is not related to a nuchal cord.
C. Periauricular papillomas.
Periauricular papillomas, also known as "ear tags,”. are small, skin-colored nodules that can be found near the external ear. They are also benign and unrelated to a nuchal cord.
D. Facial petechiae.
Facial petechiae are tiny, red or purple pinpoint spots on the skin caused by minor hemorrhages. In newborns, facial petechiae can be associated with a nuchal cord, which is a condition where the umbilical cord is wrapped around the baby's neck during delivery. This condition is relatively common and usually resolves without complications. The nurse should monitor the baby for any signs of distress or complications related to the nuchal cord.
Full Explanation
Choice A rationale:
Telangiectatic nevi are commonly known as "stork bites”. or "angel kisses”. and are superficial vascular areas commonly found on the nape of the neck or the eyelids of newborns? These are benign and pose no significant health risks.
Choice B rationale:
Erythema toxicum is a common, benign skin rash that appears in the first few days of life. It presents as small, raised red spots with a surrounding halo and is not related to a nuchal cord.
Choice C rationale:
Periauricular papillomas, also known as "ear tags,”. are small, skin-coloured nodules that can be found near the external ear. They are also benign and unrelated to a nuchal cord.
Choice D rationale:
Facial petechiae are tiny, red or purple pinpoint spots on the skin caused by minor haemorrhages. In newborns, facial petechiae can be associated with a nuchal cord, which is a condition where the umbilical cord is wrapped around the baby's neck during delivery. This condition is relatively common and usually resolves without complications. The nurse should monitor the baby for any signs of distress or complications related to the nuchal cord.
A nurse is caring for a client who has bladder distention following a vaginal birth. Which of the following actions should the nurse take first?
A. Offer the client a sitz bath.
Offering the client a sitz bath may provide some relief, but it does not address the underlying issue of bladder distention. The priority is to address the bladder distention directly.
B. Insert a urinary catheter.
Inserting a urinary catheter is not the first-line intervention for bladder distention after a vaginal birth. Catheterization carries a risk of infection and trauma, so it should only be done if other interventions are not effective.
C. Assist the client to the bathroom.
Assisting the client to the bathroom is the first action the nurse should take. Bladder distention can occur after birth due to the pressure on the bladder during labor and birth. Encouraging the client to empty her bladder will relieve the distention and promote comfort.
D. Pour warm water over the client's perineum.
Pouring warm water over the client's perineum might provide some comfort, but it does not address the bladder distention itself.
Full Explanation
Choice A rationale:
Offering the client a sitz bath may provide some relief, but it does not address the underlying issue of bladder distention. The priority is to address the bladder distention directly.
Choice B rationale:
Inserting a urinary catheter is not the first-line intervention for bladder distention after vaginal birth. Catheterization carries a risk of infection and trauma, so it should only be done if other interventions are not effective.
Choice C rationale:
Assisting the client to the bathroom is the first action the nurse should take. Bladder distention can occur after birth due to the pressure on the bladder during labour and birth. Encouraging the client to empty her bladder will relieve the distention and promote comfort.
Choice D rationale:
Pouring warm water over the client's perineum might provide some comfort, but it does not address the bladder distention itself.