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 A

Explanation

This is because circumcision is a surgical procedure that involves cutting off the foreskin of the penis, which may affect the urinary function of the baby.The nurse should make sure that the baby can urinate normally and without pain after the circumcision.

The amount of urine should be adequate for the baby’s weight and hydration status.

Choice B is wrong because the erectile ability of the penis is not affected by circumcision and is not a priority for discharge planning.

Choice C is wrong because the position of the urethral opening on the penis is not related to circumcision and should be assessed at birth, not at discharge.

Choice D is wrong because the presence of a small amount of white-yellow exudate around the glans tissue is normal and expected after circumcision.It is part of the healing process and does not indicate infection.The nurse should instruct the parents on how to care for the circumcised penis and when to seek medical attention if there are signs of complications.

A. "The discharge that you are describing is normal at this time." B. "Have you been running a fever?". C. “It sounds as if you have begun to ovulate again." D. "Are you taking iron supplements?".

Correct Answer is A

Explanation

The correct answer is choice A: “The discharge that you are describing is normal at this time.” This is because the client is experiencing lochia serosa, which is a brownish discharge that occurs from about day 4 to day 10 postpartum.

Lochia serosa is composed of old blood, serum, leukocytes, and tissue debris.

It indicates that the placental site is healing and the uterus is involuting.

Choice B is wrong because fever is a sign of infection, not normal lochia.

Choice C is wrong because ovulation usually does not resume until 6 weeks postpartum for nonbreastfeeding women and later for breastfeeding women.

Choice D is wrong because iron supplements do not affect lochia color or amount.

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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

A baby boy is circumcised on the day of discharge. Which observation should the nurse make prior to the infant’s discharge?.

Correct Answer is A

Explanation

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?

Correct Answer is A

Explanation

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

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 had an episiotomy during her delivery. Which nursing action should be included in her plan of care for the first 12 hours?

A patient comes to the family planning clinic requesting information.Which information should the nurse obtain initially to determine the patient’s knowledge base?.

During a regular clinic visit, a patient who is 28 weeks pregnant reports leg cramps. The nurse teaches the patient measures to relieve the cramps. Which statement would indicate that the patient understands the teaching?

A patient who is 26 weeks pregnant has gestational diabetes and is to begin insulin management. When discussing the patient’s insulin needs, which information should the nurse include?

On her second postpartum day, the mother of a newborn says, “The doctor says the baby has physiologic jaundice. Even though it is supposed to be normal, I don’t understand why it occurs.” Which fact regarding physiologic jaundice should form the basis of the nurse’s response?

A patient who is 38 weeks pregnant is admitted to the hospital in active labor. On admission, the patient says, “For the past ten hours, I have been leaking small amounts of urine.” Which action should the nurse take initially?

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?