A nurse in an antepartum unit is caring for a client.
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Nurses' Notes
2230:
Contractions occurring every 2.5 to 3 minutes, lasting 60 to 70 seconds. Epidural placed by anesthesiologist. Client rates pain with contractions as a 3 on a scale of 0 to 10. FHR 150/min with moderate variability. Accelerations present, no decelerations noted.
Vital Signs
2230:
Temperature 38° C (100.4° F)
Heart rate 88/min
Respiratory rate 16/min
Blood pressure 122/80 mm Hg
Oxygen saturation 98% on room air
Client rates pain with contractions as a 3 on a scale of 0 to 10
FHR 150/min with moderate variability. Accelerations present, no decelerations noted
Heart rate 88/min
Respiratory rate 16/min
Blood pressure 122/80 mm Hg
Oxygen saturation 98% on room air
The Correct Answer is ["A","B","C","D","E"]
- Heart rate decreased from 104/min to 88/min, indicating improved hemodynamic stability.
- Respiratory rate decreased from 20/min to 16/min, suggesting relaxation and reduced distress.
- Blood pressure slightly decreased from 132/84 mm Hg to 122/80 mm Hg, indicating improved comfort and reduced pain-related stress response.
- Pain level decreased to 3/10 after epidural placement, demonstrating effective pain management.
- FHR 150/min with moderate variability and accelerations present, no decelerations, indicating fetal well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Iron supplementation does not have a significant interaction with spironolactone.
B. Magnesium is not contraindicated with spironolactone, though excessive intake should be monitored.
C. Calcium does not pose a major risk when taken with spironolactone.
D. Potassium should be avoided because spironolactone is a potassium-sparing diuretic, which can lead to hyperkalemia, a potentially life-threatening condition characterized by cardiac arrhythmias and muscle weakness.
Correct Answer is D
Explanation
A. Constipation is a common side effect of risperidone due to its anticholinergic effects. However, it is not the priority because it is not immediately life-threatening.
B. Visual disturbances can occur with risperidone, but they are not as urgent as cardiovascular abnormalities.
C. Dry mouth is another anticholinergic side effect, but it is not a priority concern compared to an irregular pulse.
D. Irregular pulse is the priority finding because risperidone can prolong the QT interval, increasing the risk of serious cardiac arrhythmias, including torsades de pointes, which can be life-threatening. Therefore, this finding should be reported to the provider immediately.
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