A nurse is caring for a client who delivered a newborn by caesarean section birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse take

You can splint the incision with a pillow when changing positiion

You should change position as little as possible

You should use patterned paced breathing when changing positions

You can apply counterpressure to your back with each position change

Answer and Explanation

The Correct Answer is A

A) You can splint the incision with a pillow when changing position: Splinting the incision with a pillow is an excellent nonpharmacological method to manage pain during position changes after a cesarean section. The pillow helps provide support to the incision site, reduces strain on the abdominal muscles, and minimizes discomfort when the client moves. This is a safe and effective intervention to help with pain management.

B) You should change position as little as possible: While minimizing movement might seem like a way to prevent pain, it can lead to complications like muscle stiffness, poor circulation, and respiratory issues. It’s important for clients to change positions to promote comfort, circulation, and lung expansion, but they should do so with support to manage pain effectively.

C) You should use patterned paced breathing when changing positions: Patterned paced breathing is a helpful relaxation technique that can be used in various situations, including labor and delivery. However, it is not the most appropriate response in this context, as the client’s pain is more related to physical discomfort from the incision, and physical support (like splinting the incision) would be more effective in managing this type of pain.

D) You can apply counterpressure to your back with each position change: While counterpressure can be beneficial for back pain during labor, it is not the most relevant technique for managing pain after a cesarean section, where the pain is related to the abdominal incision site. Splinting the incision provides more targeted support for post-cesarean discomfort.

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Correct Answer is ["B","D","E"]

Explanation

A) Mongolian spots: Mongolian spots are common in newborns of Asian, Hispanic, and African descent and are not specifically associated with fetal alcohol syndrome (FAS). These spots are bluish-gray or purple and typically fade over time, but they are not a manifestation of FAS.

B) Microcephaly: Microcephaly, which is an abnormally small head, is a common feature of fetal alcohol syndrome. This condition results from the effects of alcohol on the developing brain during pregnancy, leading to a smaller-than-normal head size.

C) Single palmar crease: A single palmar crease is a common finding in Down syndrome and can occur in other conditions as well, but it is not a hallmark feature of fetal alcohol syndrome. While it may occasionally be seen in infants with FAS, it is not one of the most common or defining characteristics.

D) Thin upper lip: A thin upper lip is one of the hallmark facial features of fetal alcohol syndrome. It is part of the characteristic "facial dysmorphology" seen in FAS, along with other features such as a smooth philtrum

E) Small eyes: Small eyes, or microphthalmia, are also a characteristic feature of fetal alcohol syndrome. This abnormal eye size, along with other facial abnormalities, is often seen in infants affected by FAS.

A. Slurred speech B. Constipation C. Hypotension D. New onset of hearing loss

Correct Answer is D

Explanation

A) Slurred speech:
Slurred speech is not a common adverse effect of gentamicin. It could indicate neurological issues, but it is not typically associated with gentamicin use. If this occurs, the nurse should investigate other possible causes, such as a stroke or another neurological condition, rather than attributing it to the gentamicin.

B) Constipation:
Constipation is not a typical adverse effect of gentamicin. While antibiotics can sometimes cause gastrointestinal disturbances, gentamicin is more commonly associated with nephrotoxicity and ototoxicity, rather than constipation. If constipation occurs, it is more likely related to other factors such as diet or fluid intake.

C) Hypotension:
While hypotension can be a side effect of many medications, it is not a specific or common adverse effect of gentamicin. Gentamicin is more likely to cause nephrotoxicity and ototoxicity rather than significant blood pressure changes. However, hypotension could occur in the context of an infection or severe illness and should be monitored, but it is not directly associated with gentamicin.

D) New onset of hearing loss:
This is a well-known adverse effect of gentamicin. Gentamicin belongs to the class of antibiotics known as aminoglycosides, which can cause ototoxicity. New onset of hearing loss or tinnitus (ringing in the ears) is a significant warning sign of ototoxicity, which can occur due to gentamicin use. This side effect should be monitored closely, and if hearing loss occurs, the medication should be reevaluated, and alternatives should be considered.

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A nurse is caring for a client who delivered a newborn by caesarean section birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse take

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a newborn who has fetal alcohol syndrome. Which of the following manifestations should the nurse (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

A nurse is collecting data from a client who has pyelonephritis and receiving gentamicin via IV infusion. Which of the following manifestation should the nurse identify as an adverse effect of the treatment?

Correct Answer is D

Explanation

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