Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is in labor and just received epidural anesthesia. The client's blood pressure is 90/50 mm Hg.
Which of the following actions should the nurse take?
A. Initiate an amnioinfusion for the client.
Choice A) is not correct because initiating an amnioinfusion is not mentioned as an immediate intervention for low blood pressure after epidural anesthesia .
B. Turn the client onto their side.
It’s normal for blood pressure to fall a little when a client receives an epidural. If necessary, fluids and medicine can be given through a drip to keep blood pressure normal.
C. Monitor the client's blood pressure every 15 min.
Choice C) is not correct because monitoring the client’s blood pressure every 15 min is not mentioned as an immediate intervention for low blood pressure after epidural anesthesia .
D. Administer naloxone to the client.
Choice D) is not correct because administering naloxone to the client is not mentioned as an immediate intervention for low blood pressure after epidural anesthesia .
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Maternal Newborn 2019 with NGN Proctored Exam. Take the full exam now
Full Explanation
It’s normal for blood pressure to fall a little when a client receives an epidural.
If necessary, fluids and medicine can be given through a drip to keep blood pressure normal.
Choice A) is not correct because initiating an amnioinfusion is not mentioned as an immediate intervention for low blood pressure after epidural anesthesia .
Choice C) is not correct because monitoring the client’s blood pressure every 15 min is not mentioned as an immediate intervention for low blood pressure after epidural anesthesia .
Choice D) is not correct because administering naloxone to the client is not mentioned as an immediate intervention for low blood pressure after epidural anesthesia .
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. Prepare for surgical closure after 72 hr.
Preparing for surgical closure after 72 hours is incorrect. Surgical closure is typically performed within the first 24 to 48 hours to prevent infection and further damage to the neural tissue.
B. Administer broad-spectrum antibiotics.
Administering broad-spectrum antibiotics is crucial to prevent infection, especially since the cerebrospinal fluid is leaking, which increases the risk of meningitis and other infections.
C. Cleanse the site with povidone-iodine.
Cleansing the site with povidone-iodine is not recommended because it can be irritating and potentially harmful to the exposed neural tissue.
D. Monitor the rectal temperature every 4 hr.
Monitoring the rectal temperature every 4 hours is not appropriate as it can increase the risk of infection and trauma to the site. Axillary temperature monitoring is preferred.
Full Explanation
The correct answer is. Administering broad-spectrum antibiotics.
Cleansing the site with povidone-iodine is not recommended because it can be irritating and potentially harmful to the exposed neural tissue.
Monitoring the rectal temperature every 4 hours is not appropriate as it can increase the risk of infection and trauma to the site. Axillary temperature monitoring is preferred.
Preparing for surgical closure after 72 hours is incorrect. Surgical closure is typically performed within the first 24 to 48 hours to prevent infection and further damage to the neural tissue.
Administering broad-spectrum antibiotics is crucial to prevent infection, especially since the cerebrospinal fluid is leaking, which increases the risk of meningitis and other infections.
A nurse is planning care for a client following a chorionic villus sampling.
The nurse should recognize that the client is at risk for developing which of the following complications?
A. Anemia
Choice A is incorrect because anemia is not a known complication of CVS.
B. Infection
Chorionic villus sampling (CVS) is a prenatal test that involves taking a sample of tissue from the placenta to test for chromosomal abnormalities and certain other genetic problems. As with all types of surgical procedures, infections can happen during or after CVS.
C. Late decelerations
Choice C is incorrect because late decelerations are a type of fetal heart rate patern that can occur during labor and are not related to CVS.
D. Placental insufficiency.
Choice D is incorrect because placental insufficiency is a condition where the placenta is unable to provide enough oxygen and nutrients to the fetus and is not a known complication of CVS.
Full Explanation
Chorionic villus sampling (CVS) is a prenatal test that involves taking a sample of tissue from the placenta to test for chromosomal abnormalities and certain other genetic problems.
As with all types of surgical procedures, infections can happen during or after CVS2.
Choice A is incorrect because anemia is not a known complication of CVS.
Choice C is incorrect because late decelerations are a type of fetal heart rate patern that can occur during labor and are not related to CVS.
Choice D is incorrect because placental insufficiency is a condition where the placenta is unable to provide enough oxygen and nutrients to the fetus and is not a known complication of CVS.
A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation.
Which of the following findings should the nurse identify as a contraindication to the use of a suppository?
A. Abdominal distention
Choice A is incorrect because abdominal distention is not a contraindication to the use of a suppository.
B. Afterpains
Choice B is incorrect because afterpains are common postpartum uterine contractions and are not a contraindication to the use of a suppository.
C. Vaginal candidiasis
Choice C is incorrect because vaginal candidiasis is a fungal infection and is not a contraindication to the use of a suppository.
D. Third-degree perineal laceration.
A third-degree perineal laceration is a tear that extends through the vaginal tissue, perineal skin, and perineal muscles and involves the anal sphincter. This type of laceration requires careful repair and management to prevent complications such as infection, fecal incontinence, and pain.
Full Explanation
A third-degree perineal laceration is a tear that extends through the vaginal tissue, perineal skin, and perineal muscles and involves the anal sphincter.
This type of laceration requires careful repair and management to prevent complications such as infection, fecal incontinence, and pain.
Choice A is incorrect because abdominal distention is not a contraindication to the use of a suppository.
Choice B is incorrect because afterpains are common postpartum uterine contractions and are not a contraindication to the use of a suppository.
Choice C is incorrect because vaginal candidiasis is a fungal infection and is not a contraindication to the use of a suppository.