At 0600, while admitting a woman for a scheduled repeat cesarean section (C-section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?

Start prescribed IV with lactated Ringer’s.

Inform the anesthesia care provider.

Ensure preoperative lab results are available.

Contact the client’s obstetrician.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Starting IV fluids is essential but not the priority in this situation. Caffeine intake may alter anesthesia effects, and the anesthesiologist needs to be informed first.

Choice B rationale

Informing the anesthesia care provider is crucial because caffeine can affect anesthesia administration and increase the risk of complications, such as increased gastric acidity and delayed gastric emptying.

Choice C rationale

Ensuring preoperative lab results is important, but it is not the immediate priority compared to informing the anesthesia care provider about the caffeine intake, which directly impacts anesthesia management.

Choice D rationale

Contacting the obstetrician is necessary but secondary. The immediate priority is to inform the anesthesia care provider about the caffeine intake, which has direct implications for anesthesia and surgical safety.

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Correct Answer is A

Explanation

Choice A rationale

Postpartum preeclampsia symptoms include headache, nausea, dizziness, weakness, and visual disturbances due to increased blood pressure. Normal BP is <120/80 mmHg. Labs may show elevated liver enzymes and proteinuria.

Choice B rationale

Infections postpartum can cause fever, localized pain, and discharge but are less likely to present with headache, nausea, dizziness, and visual disturbances. Normal WBC is 4,000-11,000 cells/mcL.

Choice C rationale

Anemia due to blood loss may cause fatigue, dizziness, and weakness but usually doesn't present with headache and visual disturbances. Normal hemoglobin is 12-16 g/dL for women.

Choice D rationale

Normal postpartum fatigue generally doesn't include severe headache, nausea, dizziness, and visual disturbances. It is mainly characterized by tiredness and mild discomfort as the body recovers.

A. Notify child protective services of the client’s illicit drug use and probable child endangerment. B. Praise the client for her actions and offer to discuss ways to decrease consumption even more. C. Refer the client to an outpatient alcohol abuse program for disulfiram therapy. D. Insist that the client stop all alcohol use and draw a blood alcohol level at each prenatal visit.

Correct Answer is B

Explanation

Choice A rationale

Notifying child protective services without further assessment may cause unnecessary distress and legal complications. The client's current alcohol use reduction efforts should be considered, and other interventions can be explored first.

Choice B rationale

Praising the client for reducing alcohol intake encourages positive behavior. Providing support and discussing ways to further decrease consumption promotes a collaborative approach to reducing alcohol exposure during pregnancy.

Choice C rationale

Disulfiram therapy is not suitable for pregnant clients due to potential risks. Instead, referral to an outpatient alcohol abuse program for counseling and support is more appropriate and safer for both mother and fetus.

Choice D rationale

Insisting on complete alcohol cessation without providing support may result in non-compliance. Drawing blood alcohol levels at each visit may cause anxiety and is not a practical approach for monitoring alcohol use in pregnancy.

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At 0600, while admitting a woman for a scheduled repeat cesarean section (C-section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A client at 9 weeks gestation tells the nurse that while she has cut down, she still has at least one alcoholic drink every evening before bedtime. Which intervention should the nurse implement?

Correct Answer is B

Explanation

A diabetic client delivers a full-term large-for-gestational-age (LGA) infant who is jittery. Which action should the nurse take first?

When is the best time to administer a rubella vaccine to a client?

Assessment findings of a 4-hour-old newborn include murmur, irregular respiratory rate at 64 breaths/min, heart rate of 150 beats/min with soft murmur, jitteriness, hypotonic, and weak cry. Based on these findings, which action should the nurse implement?

A client whose labor is being augmented with an oxytocin infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a -2 station. Which action should the nurse implement first?

At 0600, while admitting a woman for a scheduled repeat cesarean section (C-section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?

A client in active labor receives a prescription for oxytocin 6 milliunits/minute intravenously (IV). The IV bag contains oxytocin 10 units in lactated Ringer’s 1,000 mL. How many mL/hour should the nurse program the infusion pump to deliver? (Enter numerical value only.)