A patient who is 37 weeks pregnant and has gestational diabetes is admitted to the labor and delivery unit for induction.
The patient is placed on an external fetal monitor and receives an epidural anesthesia.Which action should the nurse take to identify a potential side effect of the epidural?

Assess the patient’s urine for acetone.

Monitor the patient’s deep tendon reflexes.

Assess the patient’s pupillary accommodation.

Monitor the patient’s blood pressure.

Answer and Explanation

The Correct Answer is D

This is because epidural anesthesia can cause hypotension (low blood pressure) which can affect the placental blood flow and fetal oxygenation.

The nurse should monitor the patient’s blood pressure frequently and intervene if it drops below the baseline.

Choice A is wrong because assessing the patient’s urine for acetone is not relevant to the side effects of epidural anesthesia. Acetone in urine can indicate diabetic ketoacidosis, a complication of diabetes that occurs when the body breaks down fat for energy due to lack of insulin.

However, this is not related to epidural anesthesia.

Choice B is wrong because monitoring the patient’s deep tendon reflexes is not relevant to the side effects of epidural anesthesia. Deep tendon reflexes can be affected by magnesium sulfate, a medication used to prevent seizures in patients with preeclampsia (a condition characterized by high blood pressure and proteinuria in pregnancy).

However, this is not related to epidural anesthesia.

Choice C is wrong because assessing the patient’s pupillary accommodation is not relevant to the side effects of epidural anesthesia.

Pupillary accommodation is the ability of the eye to adjust its focus from distant to near objects. It can be impaired by drugs that affect the nervous system, such as opioids or anticholinergics.

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Correct Answer is D

Explanation

The correct answer is choice D. If the client feels like she has butterflies in her stomach, it means her baby is moving.

This is a normal and expected change during pregnancy, especially in the second and third trimesters.The baby’s movements can be felt as flutters, kicks, or rolls.

Choice A is wrong because spotting of blood on the underwear is not a normal change during pregnancy.

It can indicate a problem such as placenta previa, placental abruption, or miscarriage.Any bleeding during pregnancy should be reported to the health care provider.

Choice B is wrong because clear fluid leaking from the vagina is not a normal change during pregnancy.

It can indicate that the membranes have ruptured and amniotic fluid is escaping.

This can lead to infection and preterm labor if not treated promptly.Any fluid leakage during pregnancy should be reported to the health care provider.

Choice C is wrong because dark patches on the face are not a sign of high blood pressure during pregnancy.

They are called melasma or chloasma and are caused by increased pigmentation due to hormonal changes.They usually fade after delivery and are not harmful.High blood pressure during pregnancy can cause symptoms such as headache, blurred vision, swelling, and protein in the urine.

A. The breast milk can be sterilized to kill the HIV virus, then bottle-fed to the infant. B. Colostrum should be expressed and analyzed for the presence of the HIV virus prior to breastfeeding. C. Breastfeeding may be initiated if the infant is determined to be HIV positive. D. Breastfeeding may be a mode of transmission of the HIV virus.

Correct Answer is D

Explanation

This is based on the fact that HIV is a virus that attacks the body’s immune system and is spread through certain body fluids, including breast milk.Perinatal transmission can occur during pregnancy, birth, or breastfeeding.Treatment for HIV (antiretroviral therapy, or ART) substantially reduces the risk of perinatal transmission.

Choice A is wrong because sterilizing breast milk does not kill the HIV virus.

Choice B is wrong because colostrum can also contain the HIV virus and testing it is not feasible or reliable.

Choice C is wrong because breastfeeding may still pose a risk of HIV transmission even if the infant is determined to be HIV positive.

The current recommendation in the United States supports shared decision-making between mothers and their healthcare providers regarding infant feeding.Mothers who have questions about breastfeeding or who want to breastfeed should receive patient-centered, evidence-based counseling on infant feeding options, allowing for shared decision-making.

Counseling should begin before conception, or as early as possible in pregnancy and should be

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A patient who is 37 weeks pregnant and has gestational diabetes is admitted to the labor and delivery unit for induction. The patient is placed on an external fetal monitor and receives an epidural anesthesia.Which action should the nurse take to identify a potential side effect of the epidural?

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Naxlex Comprehensive Predictor Exams

The nurse provides a 16-year-old client with information concerning expected and possible changes during pregnancy. Which statement, if made by the client, would indicate that she understands the information?

Correct Answer is D

Explanation

A mother of a 3-hour-old infant requests information concerning breastfeeding. The mother has tested positive for human immunodeficiency virus (HIV).A nurse’s response should be based on which fact?

Correct Answer is D

Explanation

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A patient who is 37 weeks pregnant and has gestational diabetes is admitted to the labor and delivery unit for induction.
The patient is placed on an external fetal monitor and receives an epidural anesthesia.Which action should the nurse take to identify a potential side effect of the epidural?