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. Apply petrolatum to the patient’s perineum.This is because petrolatum can help soothe and protect the perineal area, which may be swollen, bruised, or have stitches after a vaginal delivery.Applying petrolatum can also prevent the pad from sticking to the wound and causing more pain.

Choice A is wrong because observing the patient for vaginal discharge of bright red blood is not a specific action for perineal care.Bright red blood may indicate postpartum hemorrhage, which requires immediate medical attention.

Choice B is wrong because assessing the patient’s vaginal tone is not a priority action for perineal care.Vaginal tone may be reduced after childbirth due to stretching of the pelvic floor muscles, but this can improve with time and exercises.

Choice C is wrong because massaging the patient’s perineum is not recommended for perineal care.Massaging the perineum may cause more trauma and discomfort to the area, especially if there are stitches or hemorrhoids.Massaging the fundus (the top of the uterus) may be done to help it contract and prevent bleeding, but this is different from massaging the perineum.

A. “I will use one breast at each feeding and switch to the second breast at the next feeding.”. B. “I will rub breast milk into my nipple.”. C. “I will wash my nipples with water but no soap, and I will let them air dry.”. D. “I will place warmed tea bags on my nipples.”. E. “I will place warmed tea bags on my nipples.”.

Correct Answer is D

Explanation

The correct answer is choice D. Placing warmed tea bags on the nipples is not a recommended method to avoid nipple soreness while breastfeeding.Tea bags can cause dryness and cracking of the nipples, which can increase the risk of infection and pain.

Choice A is wrong because it is better to use both breasts at each feeding and switch the starting breast at each feeding.This helps to ensure adequate milk production and drainage.

Choice B is correct because rubbing breast milk into the nipple can help to moisturize and protect the nipple from infection.Breast milk has antibacterial and healing properties.

Choice C is correct because washing the nipples with water but no soap can help to prevent irritation and dryness of the nipples.

Soap can remove the natural oils that protect the skin.Letting the nipples air dry can also help to prevent fungal growth.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the postpartal admission assessment, the nurse notes that a patient’s perineum appears edematous and ecchymotic. Based on this finding, which action should the nurse take?

Correct Answer is D

Explanation

The nurse instructs a class of postpartum women on methods to avoid nipple soreness while breastfeeding. Which comment by a class participant indicates the need for further instruction?

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?

A client who is two weeks postpartum calls the office and tells a nurse, "l am having a small amount of brownish discharge from my vagina." Which response is appropriate for the nurse to make?

A client who is 22 weeks pregnant with a twin gestation comes to the clinic. The nurse instructs the client in self-care for the third trimester of pregnancy. Which statement made by the client would indicate the need for further teaching?

A patient who is 17 weeks pregnant shares several pieces of information with the nurse. Which statement made by the patient would indicate the patient is at risk for having an infant with intrauterine growth retardation (IUGR)?

A nurse is caring for a patient who is in labor and is placed on a monitor.How should the nurse determine the duration of contractions?

A patient has decided to bottle-feed her twins.The nurse should give this patient which instruction to help alleviate breast engorgement?

A 14-year-old patient visits the antepartal clinic because she has missed three menstrual periods.The patient is to have a pelvic examination. In addition to explaining the procedure, which measure would best help reduce the patient’s anxiety?

During a class for women in the second trimester of pregnancy, the nurse discusses methods to alleviate back pain. Which statement by a class member would indicate the need for additional instruction?

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?