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. Encourage the client to drink cold, carbonated fluids throughout the day.This helps to relieve the shoulder pain caused by the carbon dioxide gas used to inflate the abdomen during laparoscopy.

The gas irritates the diaphragm, which refers pain to the shoulder.Drinking cold, carbonated fluids can help expel the gas and reduce the pain.

Choice A is wrong because an abdominal binder is not necessary for a laparoscopic procedure.It is more commonly used for abdominal surgeries that involve a large incision.

Choice B is wrong because a rocking chair is not helpful for a client who had a laparoscopic BTL.It is more useful for a client who had a vaginal delivery to promote comfort and uterine involution.

Choice C is wrong because keeping the head of the bed flat for six hours is not indicated for a laparoscopic BTL.It may increase the risk of venous thromboembolism and pulmonary embolism due to prolonged immobility.The client should be encouraged to ambulate as soon as possible after surgery.

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

A client had a laparoscopic bilateral tubal ligation (BTL) in the delivery room. Which intervention should a nurse plan to include in this client’s postoperative care?

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

A nurse is caring for a patient who is 40 weeks pregnant. Which finding would indicate the need for a cesarean delivery?

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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?

A client is at the antepartal clinic for a pregnancy test.Which finding, if present, would be considered a positive sign of pregnancy?

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The physician prescribes prostaglandin (PGE2) gel for a patient being admitted for induction of labor. Which finding would best indicate that the prostaglandin gel is effective?

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 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?