A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 min and a frequency of 3 min. The nurse obtains the following vital signs: fetal heart rate 130/min. maternal heart rate 128/min and maternal blood pressure 92/54 mm Hg. Which of the following is the priority action for the nurse to take?

Have the client void.

Position the client with one hip elevated.

Ask the client if she needs pain medication.

Notify the provider of the findings.

Answer and Explanation

The Correct Answer is B

The correct answer is B. Position the client with one hip elevated.

A. Having the client void is a good practice, but it is not the priority action in this situation. The client's vital signs suggest a potential issue with uteroplacental perfusion, and repositioning the client should be the priority.

B. Positioning the client with one hip elevated is the priority action.

The vital signs, specifically the low blood pressure, may be indicative of aortocaval compression (supine hypotension). Elevating one hip helps alleviate this compression, improving blood flow and potentially addressing the decreased blood pressure.

C. Asking the client if she needs pain medication is important, but repositioning the client takes precedence due to the potential issue with blood pressure and uteroplacental perfusion.

D. Notifying the provider is important, but repositioning the client to improve blood flow should be done first. The provider may be notified afterward based on the client's response and ongoing assessment.

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Correct Answer is C

Explanation

The correct answer is C. Hypotension.

A. Respiratory depression is not a common complication of epidural anesthesia. It is more associated with opioid analgesics or excessive administration of other anesthetics.

B. Tachycardia is generally not associated with epidural anesthesia. It is more commonly observed in response to pain or anxiety.

C. Hypotension is a common complication of epidural anesthesia.

Epidural anesthesia can cause vasodilation, leading to a decrease in blood pressure. This is particularly common when the block is administered rapidly or with a higher dose.

D. Vomiting is not a direct complication of epidural anesthesia. Nausea and vomiting are more commonly associated with opioid analgesics or general anesthesia.

A. "You should take the medication within 72 hours following unprotected sexual intercourse." B. "You should avoid taking this medication if you are on an oral contraceptive." C. "If you don't start your period within 5 days of taking this medication, you will need a pregnancy test." D. "One dose of this medication will prevent you from becoming pregnant for 14 days after taking it”

Correct Answer is A

Explanation

Choice A Reason:

"You should take the medication within 72 hours following unprotected sexual intercourse." This statement is accurate. Levonorgestrel is an emergency contraceptive that is effective when taken within 72 hours (3 days) after unprotected sexual intercourse. It is crucial to use it as soon as possible for optimal effectiveness in preventing pregnancy.

Choice B Reason:

"You should avoid taking this medication if you are on an oral contraceptive." This statement is not accurate. Levonorgestrel can be used as emergency contraception, even if the individual is already on an oral contraceptive. However, it's essential to follow the healthcare provider's guidance.

Choice C Reason:

"If you don't start your period within 5 days of taking this medication, you will need a pregnancy test." This statement is not entirely accurate. While a delayed period may occur after taking levonorgestrel, it does not necessarily indicate pregnancy. If there are concerns about pregnancy, a pregnancy test should be taken a few weeks after using emergency contraception.

Choice D Reason:

"One dose of this medication will prevent you from becoming pregnant for 14 days after taking it." This statement is not accurate. Levonorgestrel is primarily effective in the prevention of pregnancy when taken shortly after unprotected intercourse. It does not provide ongoing protection, and additional contraceptive methods should be considered for future encounters.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?

Correct Answer is C

Explanation

A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse Include in the teaching?

Correct Answer is A

Explanation

A nurse is assessing a newborn for manifestations of hypoglycemia. Which of the following findings should the nurse expect?

A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make?

A DDA nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?

A nurse is caring for a client who is receiving oxytocin for induction of labor and has an intrauterine pressure catheter (IUPC) placed to monitor uterine contractions. For which of the following contraction patterns should the nurse discontinue the infusion of oxytocin?

A nurse is assessing a newborn who is 12 hr old. Which of the following manifestations requires intervention by the nurse?

A nurse is teaching a client who is at 24 weeks of gestation regarding a 1-hr glucose tolerance test. Which of the following statements should the nurse include in the teaching?

A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?