MN C-sections/PP/NCLEX Exam 2
The obstetrician has ordered that a post-op cesarean section client's patient controlled analgesia (PCA) be discontinued. Which of the following actions by the nurse is appropriate? 1. Discard the remaining medication in the presence of another nurse. 2. Recommend waiting until her pain level is zero to discontinue the medicine. 3. Discontinue the medication only after the analgesia is completely absorbed. 4. Return the unused portion of medication to the narcotics cabinet
1. Discard the remaining medication in the presence of another nurse.
A 3-day-postpartum breastfeeding woman is being assessed. Her breasts are firm and warm to the touch. When asked when she last fed the baby her reply is, "I fed the baby last evening. I let the nurses feed him in the nursery last night. I needed to rest." Which of the following actions should the nurse take at this time? 1. Encourage the woman exclusively to breastfeed her baby. 2. Have the woman massage her breasts hourly. 3. Obtain an order to culture her expressed breast milk. 4. Take the temperature and pulse rate of the woman.
1. Encourage the woman exclusively to breastfeed her baby.
Immediately after delivery, a woman is shaking uncontrollably. Which of the following nursing actions is most appropriate? A. Provide the woman with warm blankets B. Put the woman in the trendelenburg position C. Notify the primary health care provider D. Increase IV infusion
A. Provide the woman with warm blankets
A nurse is counseling about postpartum blues. Which of the following should be included in the discussion? A. The father may become sad and weepy B. Postpartum blues last about a week or two C. Medications are available to relieve the symptoms D. Very few women experience postpartum blues
B. Postpartum blues last about a week or two
A client who delivered a 3900 gm baby vaginally over a right mediolateral episiotomy states, "How am I supposed to have a bowel movement? The stitches are right there!" Which of the following is the best response by the nurse? A. I will call the doctor to order a stool softener for you B. Your stitches are actually far way from your rectal area C. If you eat a high-fiber foods and drink fluids you should have no problems D. If you use your topical anesthetic on your stitches you will feel much less pain
B. Your stitches are actually far way from your rectal area
The surgeon has removed the surgical cesarean section dressing from a post-op day 1 client. Which of the following actions by the nurse is appropriate? 1. Irrigate the incision twice daily. 2. Monitor the incision for drainage. 3. Apply steristrips to the incision line. 4. Palpate the incision for weaknesses.
2. Monitor the incision for drainage.
One nursing diagnosis that a nurse has identified for a postpartum client is: Risk for intrauterine infection r/t vaginal delivery. During the postpartum period, which of the following goals should the nurse include in the care plan in relation to this diagnosis? Select all that apply. 1. The client will drink sufficient quantities of fluid. 2. The client will have a stable white blood cell count. 3. The client will have a normal temperature. 4. The client will have normal-smelling vaginal discharge. 5. The client will take two or three sitz baths each day.
2. The client will have a stable white blood cell count. 3. The client will have a normal temperature. 4. The client will have normal-smelling vaginal discharge.
The day after delivery a woman, whose fundus is firm at 1 cm below the umbilicus and who has moderate lochia, tells the nurse that something must be wrong, "All I do is go to the bathroom." Which of the following is an appropriate nursing response? 1. Catheterize the client per doctor's orders. 2. Measure the client's next voiding. 3. Inform the client that polyuria is normal. 4. Check the specific gravity of the next voiding.
3. Inform the client that polyuria is normal.
A client, 2 days postoperative from a cesarean section, complains to the nurse that she has yet to have a bowel movement since the surgery. Which of the following responses by the nurse would be appropriate at this time? 1. "That is very concerning. I will request that your physician order an enema for you." 2. "Two days is not that bad. Some patients go four days or longer without a movement." 3. "You have been taking antibiotics through your intravenous. That is probably why you are constipated." 4. "Fluids and exercise often help to combat constipation. Take a stroll around the unit and drink lots of fluid."
4. "Fluids and exercise often help to combat constipation. Take a stroll around the unit and drink lots of fluid."
A multigravid, postpartum woman reports severe abdominal cramping whenever she nurses her infant. Which of the following responses by the nurse is appropriate? 1. Suggest that the woman bottlefeed for a few days. 2. Instruct the patient on how to massage her fundus. 3. Instruct the patient to feed using an alternate position. 4. Discuss the action of breastfeeding hormones.
4. Discuss the action of breastfeeding hormones.
Which of the following nursing interventions would be appropriate for the nurse to perform to achieve this client care goal: The client will not develop postpartum thrombophlebitis? A. Encourage early ambulation B. Promote oral fluid intake C. Massage the legs of the client twice daily D. Provide the client with high fiber foods
A. Encourage early ambulation
A nurse is assessing a 1 day postpartum woman who had her baby by c-section. Which of the following should the nurse report to the surgeon? A. Fundus at umbilicus B. Nodular breasts C. Pulse rate 60 bpm D. Pad saturation every 30 minutes
D. Pad saturation every 30 minutes
Which of the following statements is true about breastfeeding mothers as compared to bottle-feeding mothers? A. Breastfeeding mothers usually involute completely by 2 weeks PP. B. Breastfeeding mothers have decrease incidence of diabetes mellitus later in life C. Breastfeeding mothers show higher levels of bone density after menopause D. Breastfeeding mothers are prone to fewer bouts of infection immediately postpartum
B. Breastfeeding mothers have decrease incidence of diabetes mellitus later in life
To prevent infection, the nurse teaches the postpartum client to perform which of the following tasks? A. Apply antibiotic ointment to the perineum daily B. Change the peripad at each voiding C. Void at least every 2 hours D. Spray the perineum with povidone-iodine after toileting
B. Change the peripad at each voiding
The nurse is developing a plan of care for the postpartum client during the "taking in" phase. Which of the following should the nurse include in the plan? A. Teach baby-care skills such as diapering B. Discuss the labor and birth with the mother C. Discuss contraceptive choices with the mother D. Teach breastfeeding skills such as pumping
B. Discuss the labor and birth with the mother
A nurse is assessing the fundus of a client during the immediate PP period. Which of the following actions indicates that the nurse is performing the skill correctly? A. The nurse measures the fundal height using a paper centimeter tape B. The nurse stabilizes the base of the uterus with his or her dependent hand C. The nurse palpates the fundus with the tips of his or her fingers D. The nurse precedes the assessment with a sterile vaginal exam.
B. The nurse stabilizes the base of the uterus with his or her dependent hand
The nurse has taught a new admission to the postpartum unit about pericare. Which of the following indicates that the client understands the procedure? Select all that apply. A. The woman performs the procedure twice a day B. The woman washes her hands before and after the procedure C. The woman sits in warm tap water for ten minutes three times a day. D. The woman sprays her perineum from front to back E. The woman mixes warm tap water with hydrogen peroxide
B. The woman washes her hands before and after the procedure D. The woman sprays her perineum from front to back
Which of the following laboratory values would the nurse expect to see in a normal postpartum woman? A. Hematocrit 39% B. WBC 16,000 cells/mm3 C. RBC 5,000,000 cells/mm3 D. Hemoglobin 15 gm/dL
B. WBC 16,000 cells/mm3
The nurse is assessing the midline episiotomy on a postpartum client. Which of the following findings should the nurse expect to see? A. Moderate serosanguinous drainage B. Well-approximated edges C. Ecchymotic area distal to the episiotomy D. An area of redness adjacent to the incision
B. Well-approximated edges
A physician has ordered an iron supplement for a postpartum woman. The nurse strongly suggests that the woman take the medicine with which of the following drinks? A. Skim milk B. Ginger ale C. Orange juice D. Chamomile tea
C. Orange juice
The nurse should warn a client who is about to receive Methergine of which of the following side effects? A. Headache B. Nausea C. Cramping D. Fatigue
C. Cramping *nurses should also assess the blood pressure before administration
The nurse monitors his or her postpartum clients carefully because which of the following physiological changes occurs during the early postpartum period? A. Decreased urinary output B. Increased blood pressure C. Decreased blood volume D. Increased estrogen level
C. Decreased blood volume
A 2 day postpartum mother, G2 P2002, states that her 2 year old daughter at home is very excited about taking "my baby sister" home. Which of the following is an appropriate response by the nurse? A. Its always nice when siblings are excited to have the babies go home B. Your daughter is very advanced for her age. She must speak very well C. Your daughter is likely to become very jealous of the new baby D. Older sisters can be very helpful. They love to play mother
C. Your daughter is likely to become very jealous of the new baby
A breastfeeding mother states that she has sore nipples. In response to the complaint, the nurse assists with "latch on" and recommends that the mother do which of the following? A. Use a nipple shield at each breastfeeding B. Cleanse the nipples with soap 3 times day C. rotate the baby's positions at each feed D. Bottle feed for 2 days then resume
C. rotate the baby's positions at each feed
The nurse is caring for a breastfeeding mother who asks for advise on foods that will provide both vitamin A and iron. Which of the following should the nurse recommend? A. 1/2 cup raw celery dipped in 1 ounce cream cheese B. 8 oz yogurt mixed with 1 medium banana C. 12 oz strawberry milkshake D. 1 and 1/2 cups raw broccoli
D. 1 and 1/2 cups raw broccoli
A client, G1 P1, 1 hour PP from a spontaneous vaginal delivery with local anesthesia, states that she needs to urinate. Which of the following actions by the nurse is appropriate at this time? A. Provide the woman with a bedpan B. Advise the woman that the feeling is likely related to the trauma of delivery. C. Remind the woman that she still has a catheter in place from the delivery D. Assist the woman to the bathroom
D. Assist the woman to the bathroom
A client, 2 days postpartum from a spontaneous vaginal delivery, asks the nurse about postpartum exercises. Which of the following responses by the nurse is appropriate? A. You must wait to begin to perform exercises until after your 6 week PP check up B. You may begin Kegel exercises today, but do not do any other exercises until the doctor tells you that it is safe C. By next week you will be able to return to the exercise schedule you had during your pre-pregnancy D. You can do some Kegel exercises today and then slowly increase your toning exercises over the next few weeks
D. You can do some Kegel exercises today and then slowly increase your toning exercises over the next few weeks
A post-cesarean birth woman has been diagnosed with paralytic ileus. Which of the following symptoms would the nurse expect to see? a. Abdominal distension b. Polyuria c. Diastasis recti d. Dependent edema
a. Abdominal distension *Rationale:* a. The nurse would expect to see a distended abdomen in a client with a paralytic ileus. b. Polyuria is unrelated to a paralytic ileus. c. Diastasis recti is unrelated to a paralytic ileus. d. Dependent edema is unrelated to a paralytic ileus.
A woman is 2 days postpartum from a normal vaginal delivery over an intact perineum of a 3000-gram baby. Where would the nurse expect to palpate the client's fundus? a. At the umbilicus b. 2 cm below the umbilicus c. 2 cm above the symphysis d. At the symphysis
b. 2 cm below the umbilicus *Rationale:* a. Expected location for 6 to 12 hours postpartum. b. The firm fundus should be 2 cm below the umbilicus. c. This is an abnormal finding and may be related to subinvolution of the uterus. d. Expected location for 6 days postpartum.
The perinatal nurse demonstrates for the student nurse the correct technique of postpartum uterine palpation. Support for the lower uterine segment is critical, as without it, there is an increased risk of: a. Uterine edema b. Uterine inversion c. Incorrect measurement d. Intensifying the patient's level of pain
b. Uterine inversion *Rationale:* a. Placing the hand over the base of the uterus does not cause uterine edema. b. The uterine fundus is palpated by placing one hand on the base of the uterus immediately above the symphysis pubis and the other hand at the level of the umbilicus. The nurse presses inward and downward with the hand positioned on the umbilicus until the fundus is located. It should feel like a firm, globular mass located at or slightly above the umbilicus during the first hour after birth. The uterus should never be palpated without supporting the lower uterine segment. Failure to do so may result in uterine inversion and hemorrhage. c. Measurement is the same with or without the hand supporting the lower uterine segment. d. Not supporting the lower uterine segment has no effect on the level of pain felt by the patient.
The nurse is evaluating the involution of a woman who is 3 days postpartum. Which of the following findings would the nurse evaluate as normal? A. Fundus 1 cm above the umbilicus, lochia rosa B. Fundus 2 cm above the umbilicus, lochia alba C. Fundus 2 cm below the umbilicus, lochia rubra D. Fundus 3 cm below the umbilicus, lochia serosa
d. Fundus 3 cm below the umbilicus, lochia serosa
The nurse is caring for a postpartum client who experienced a second-degree perineal laceration at delivery 2 hours ago. Which of the following interventions should the nurse perform at this time? A. Apply an ice pack to the perineum B. Advise the woman to use a sitz bath after every voiding C. Advise the woman to sit on a pillow D. Teach the woman to insert nothing into her rectum.
A. Apply an ice pack to the perineum
A client has been transferred to the post-anesthesia care unit from a c-section delivery. The client had spinal anesthesia for the surgery. Which of the following interventions should the nurse perform at this time? A. Assess the level of anesthesia B. Encourage the client to urinate in a bedpan C. Provide the client with the diet of her choice D. Check the incision for signs of infection
A. Assess the level of anesthesia
A 1 day postpartum woman states, I think I have a UTI. I have to go to the bathroom all the time. Which of the following actions should the nurse take? A. Assure the woman that frequent urination is normal after delivery B. Obtain an order for a urine culture C. Assess the urine for cloudiness D. Ask the woman if she is prone to urinary tract infections
A. Assure the woman that frequent urination is normal after delivery
A nurse is performing a postpartum assessment on a client who delivered by c-section. Which of the following actions will the nurse perform? Select all that apply. A. Auscultate abdomen B. Palpate the fundus C. Assess the nipple integrity D. Assess the central venous pressure E. Auscultate the lung fields
A. Auscultate abdomen B. Palpate the fundus C. Assess the nipple integrity E. Auscultate the lung fields
A postpartum nurse is caring for a client who received epidural anesthesia during her labor and delivery. The nurse should advise the woman that she may experience which of the following side effects of the medication during the postpartum period? A. Backache B. Light-headedness C. Hypertension D. Footdrop
A. Backache
A client who is 3 days postpartum asks the nurse, "when may my husband and I begin having sexual relations again?" The nurse should encourage the couple to wait until after which of the following has occurred? A. The client has had their 6 week postpartum check up B. The episiotomy has healed and the lochia has stopped C. The lochia has turned to pink and vagina is no longer hard D. The client has had their first postpartum menstrual period
A. The client has had their 6 week postpartum check up
A 3 day postpartum client questions why she is to receive the rubella vaccine before leaving the hospital. Which of the following rationales should guide the nurse's response? A. The client's obstetric status is optimal for receiving the vaccine B. The client's immune system is highly responsive during the postpartum period C. The client's baby will be high risk for acquiring rubella if the woman does not receive the vaccine D. The client's insurance company will pay for the shot if it is given during the immediate postpartum period
A. The client's obstetric status is optimal for receiving the vaccine
The nurse palpates a distended bladder on a woman who delivered vaginally 2 hours earlier. The woman refuses to go to the bathroom, "I really don't need to go". Which of the following responses by the nurse is appropriate? A. Okay, I must be palpating your uterus B. I understand but I still would like you to try to urinate C. You still must be numb from the local anesthesia D. That is a problem. I will have to catheterize you
B. I understand but I still would like you to try to urinate
A woman, 24 hours postpartum, is complaining of profuse diaphoresis. She has no other complaints. Which of the following actions by the nurse is appropriate? A. Take the women's temp B. Advise the woman to decrease her fluid intake C. Reassure the woman that this is normal D. Notify the neonate's pediatrician
C. Reassure the woman that this is normal
The nurse in the obstetric clinic received a telephone call from a bottle-feeding mother of a 3 day old. The client states that her breasts are firm, red, and warm to the touch. Which of the following is the best action for the nurse to advise the client to perform? A. Intermittently apply ice packs to her axillae and breasts B. Apply lanolin to her breasts and nipples every 3 hours C. Express milk from the breasts every 3 hours D. Ask the primary healthcare provider to order a milk suppressant
A. Intermittently apply ice packs to her axillae and breasts
Which of the following complementary therapies can a nurse suggest to a multiparous woman who is complaining of severe afterbirth pains? A. Lie prone with a small pillow cushioning her abdomen B. Contract her abdominal muscles for a count of ten C. Slowly ambulate in the hallways D. Drink ice tea with lemon or lime
A. Lie prone with a small pillow cushioning her abdomen
During a postpartum assessment, the nurse assesses the calves of a client's legs. The nurse is checking for which of the following signs/symptoms? Select All That Apply A. Pain B. Warmth C. Discharge D. Ecchymosis E. Redness
A. Pain B. Warmth E. Redness
A nurse is performing a postpartum assessment on a client who delivered vaginally. Which of the following action will the nurse perform? Select All That Apply A. Palpate breasts B. Auscultate carotid C. Check vaginal discharge D. Assess the extremities E. Inspect the perineum
A. Palpate breasts C. Check vaginal discharge D. Assess the extremities E. Inspect the perineum
Which of the following is the priority nursing action during the immediate postpartum period? A. Palpate fundus B. Check pain level C. Perform pericare D. Assess breasts
A. Palpate fundus
A 3 day breastfeeding client who is not immune to rubella is to receive the rubella vaccine at discharge. Which of the following must the nurse include in her discharge teaching regarding the vaccine? A. The woman should not become pregnant for at least 4 weeks B. The woman should pump and dump her breast milk for 1 week C. Surgical masks must be worn by the mother when she holds the baby D. Antibodies transported through the breast milk will protect the baby
A. The woman should not become pregnant for at least 4 weeks
The nurse has provided teaching to a postop c-section client who is being discharged on Colace 100mg PO TID. Which of the following would indicate that the teaching was successful? A. The woman swallows the tablets whole B. The woman takes the pills between meals C. The woman calls the doctor if she develops a headache D. The woman understand that her urine may turn orange.
A. The woman swallows the tablets whole
A client is receiving an epidural infusion of a narcotic for pain relief after a c-section. The nurse would report to the anesthesiologist if which of the following were assessed? A. respiratory rate of 8 rpm B. complaint of thirst C. urinary output of 250 mL/hr D. numbness of feet and ankles
A. respiratory rate of 8 rpm
A maternity nurse knows that obstetric clients are most at high risk for cardiovascular compromise during the one hour immediately following a delivery because of which of the following? A. Weight of the uterine body is significantly reduced B. Excess blood volume from pregnancy is circulating in the woman's periphery C. Cervix if fully dilated and the lochia flows freely D. Maternal blood pressure drops precipitously once the baby's head emerges
B. Excess blood volume from pregnancy is circulating in the woman's periphery
A breastfeeding client, G10 P6408, delivered 10 minutes ago. Which of the following assessments is most important for the nurse to perform at this time? A. Pulse B. Fundus C. Bladder D. Breast
B. Fundus
During a home visit, the nurse assesses a client 2 weeks after delivery. Which of the following signs/symptoms should the nurse expect to see? A. Diaphoresis B. Lochia Alba C. Cracked nipples D. Hypertension
B. Lochia Alba
A client, G1 P0101, postpartum 1 day is assessed. The nurse notes that the client's lochia rubra is moderate and her fundus is boggy 2 cm above the umbilicus and deviated to the right. Which of the following actions should the nurse take first? A. Notify the woman's PCP B. Massage the woman's fundus C. Escort the woman to the bathroom to urinate D. Check the quantity of lochia on the peripad
B. Massage the woman's fundus
The third stage of labor has just ended for a client who has decided to bottle feed her baby. Which of the following maternal hormones will increase sharply at this time? A. Estrogen B. Prolactin C. HPL D. HCG
B. Prolactin
A breastfeeding woman has been counseled on how to prevent engorgement. Which of the following actions by the mother shows that the teaching was effective? A. She pumps her breasts after each feeding B. She feeds her baby every 2-3 hours C. She feeds her baby 10 minutes on each side D. She supplements each feeding with formula
B. She feeds her baby every 2-3 hours
The nurse is discussing the importance of doing Kegel exercises during the postpartum period. Which of the following should be included in the teaching plan? A. She should repeatedly contract and relax her rectal and thigh muscles B. She should practice by stopping the urine flow midstream every time she voids C. She should get on her hands and knees whenever performing the exercises D. She should be advised that the her Kegel exercises should be performed during all bowel movements
B. She should practice by stopping the urine flow midstream every time she voids
A woman is receiving patient-controlled analgesia (PCA) post-cesarean section. Which of the following must be included in the patient teaching? A. The client should monitor how often she presses the button B. The client should report any feelings of nausea or itching to the nurse C. The family should press the button whenever they feel the woman is in pain D. the family should inform the nurse if the client becomes sleepy
B. The client should report any feelings of nausea or itching to the nurse
A mother, G1 P1, who delivered a 2800 gm baby vaginally 30 minutes earlier, is transferred to the postpartum unit. She pushed for 45 minutes and the placenta was delivered 10 minutes later. She is receiving an IV with 20 unites Oxytocin added. The postpartum nurse questions why the oxytocin was added to the IV bag. Which of the following responses by the transferring nurse is most likely? A. The medication was added 10 minutes ago to prevent excess bleeding during her transfer B. The medication was added immediately after the baby's birth to promote placental delivery C. The medication was added after the placenta was delivered because of its rapid separation D. The medication was added while she was pushing to speed up the baby's birth
B. The medication was added immediately after the baby's birth to promote placental delivery
A breastfeeding woman, 1 and 1/2 months postdelivery, calls the nurse in the obstetricians' office and states, "I am very embarrassed but I need help. Last night I had an orgasm when my husband and I were making love. You should have seen the milk. We were both soaking wet. What is wrong with me?" The nurse should base the response to the client on which of the following? A. The woman is exhibiting signs of pathological galactorrhea B. The same hormone stimulates orgasms and the milk ejection reflex C. The woman should have a serum galactosemia assessment done D. The baby is stimulating the woman to produce too much milk
B. The same hormone stimulates orgasms and the milk ejection reflex
A post c-section, breastfeeding client whose subjective pain level is 2/5 requests her as needed (PRN) narcotic analgesics every 3 hours. She states, "I have decided to make sure that I feel as little pain from this experience as possible". Which of the following should the nurse conclude in relation to this woman's behavior? A. The woman needs a stronger narcotic order B. The woman is high risk for severe constipation C. The woman's breast milk volume may drop while taking the medicine D. The woman's newborn may become addicted to the medication
B. The woman is high risk for severe constipation
The nurse is care for a client, postop 1 day from an emergency c-section with her husband in attendance. The baby's Apgar was 9/9. The woman and her partner had attended childbirth education classes and had anticipated having a water birth with family present. Which of the following comments by the nurse is appropriate? A. Sometimes babies just dont deliver the way we expect them to B. With all of your preparations, it must have been disappointing for you to have had a c-section C. I know you had to have surgery, but you are very lucky that your baby was born healthy D. At lease your husband was able to be with you when the baby was born.
B. With all of your preparations, it must have been disappointing for you to have had a c-section
The nurse is assessing the laboratory report on a 2 day Postpartum G1 P1001. The woman had a normal postpartum assessment this morning. Which of the following results should the nurse report to the primary healthcare provider? A. WBC 12,500 cells/mm3 B. RBC 4,500,000 cells/mm3 C. HCT 26% D. Hgb 11 g/dL
C. HCT 26%
The nurse is caring for a client who had a cesarean section under spinal anesthesia less than 2 hours ago. Which of the following nursing actions is appropriate at this time? A. Elevate the head of the bed 60 degrees B. Report absence of bowel sounds to the physician C. Have her turn and deep breathe every 2 hours D. Assess for patellar hyperreflexia bilaterally
C. Have her turn and deep breathe every 2 hours
On admission to the labor and delivery unit, a client's Hgb was assessed at 11 g/dL and her Hct at 33%. Which of the following values would the nurse expect to see 2 days after a normal spontaneous vaginal delivery? A. Hgb 12.5, Hct 37% B. Hgb 11, Hct 33% C. Hgb 10.5, Hct 31% D. Hgb 9, Hct 27%
C. Hgb 10.5, Hct 31%
The home health nurse visits a client who is 6 days postdelivery. The client appears sad, weeps frequently, and states "I dont know what is wrong with me. I feel terrible. I should be happy, but Im not". Which of the following nursing diagnoses is appropriate for this client? A. Suicidal thoughts r/t psychotic ideations B. Post-trauma response r/t traumatic delivery C. Ineffective individual coping r/t hormonal shifts D. Spiritual distress r/t immature belief systems
C. Ineffective individual coping r/t hormonal shifts
A client, G2 P1102, is 30 minutes postpartum from a low forceps vaginal delivery over a right mediolateral episiotomy. Her physician has just finished repairing the incision. The client's legs are in stirrups and she is breastfeeding her baby. Which of the following actions should the nurse perform? A. Assess her feet and ankles for pitting edema B. Advise the client to stop feeding her baby while her blood pressure is assessed C. Lower both of her legs at the same time D. Measure the length of the episiotomy and document the findings in the chart
C. Lower both of her legs at the same time
The nurse is examining a 2-day postpartum client whose fundus is 2 cm below the umbilicus and whose bright red lochia saturates about 4 inches of a pad in 1 hour. What should the nurse document in the nursing record? A. Abnormal involution, lochia rubra heavy B. Abnormal involution, lochia serosa scant C. Normal involution, lochia rubra moderate D. Normal Involution, lochia serosa heavy
C. Normal involution, lochia rubra moderate
A primipara, 2 hours postpartum, requests that the nurse diaper her baby after a feeding because "I am so tired right now. I just want to have something to eat and take a nap." Based on this information, the nurse concludes that the woman is exhibiting signs of which of the following? A. Social deprivation B. Child neglect C. Normal postpartum behavior D. Postpartum depression
C. Normal postpartum behavior
The nurse is developing a standard care plan for PP clients who have had midline episiotomies. Which of the following interventions should be included in the plan? A. Assist with stitch removal on the 3rd PP day B. Administer analgesics every 4 hours per doctor's orders C. Teach the client to contract her buttocks before sitting D. Irrigate the incision twice daily with antibiotic solution
C. Teach the client to contract her buttocks before sitting
A client has just been transferred to the postpartum unit from labor and delivery. Which of the following nursing care goals is of highest priority? A. The client will breastfeed her baby every 2 hours B. The client will consume a normal diet C. The client will have a moderate lochial flow D. The client will ambulate to the bathroom every 2 hours
C. The client will have a moderate lochial flow
A breastfeeding client, 7 weeks postpartum, complains to an obstetrician's triage nurse that when she and her husband had intercourse for the first time after the delivery, "I couldn't stand it It was so painful. The doctor must have done something terrible to my vagina." Which of the following responses by the nurse is appropriate? A. After a delivery the vagina is always tender. It should feel better the next time you have intercourse B. Does your baby have thrush? If so, you should be assessed for a yeast infection in your vagina. C. Women who breastfeed often have vaginal dryness. A vaginal lubricant may remedy your discomfort D. Sometimes the stitches of episiotomies heal too tight. Why dont you come in to be checked?
C. Women who breastfeed often have vaginal dryness. A vaginal lubricant may remedy your discomfort
The nurse is developing a plan of care for the postpartum client during the "taking hold" phase. which of the following should the nurse include in the plan? A. Provide the client with a nutritious meal B. Encourage the client to take a nap C. Assist the client with activities of daily living D. Assure the client that she is an excellent mother
D. Assure the client that she is an excellent mother
A patient, G2 P1102, who delivered her baby 8 hours ago, now has a temperature of 100.2 F. Which of the following is the appropriate nursing intervention at this time? A. Notify the doctor to get an order for acetaminophen B. Request an infectious disease consult from the doctor C. Provide the woman with cool compress D. Encourage intake of water and other fluids
D. Encourage intake of water and other fluids
A woman had a c-section yesterday. She states that she needs to cough but that she is afraid to. Which of the following is the nurse's best response? A. I know that it hurts, but it is very important for you to cough B. Let me check your lung fields to see if coughing is really necessary. C. If you take a few deep breaths in, that should be as good as coughing D. If you support your incision with a pillow, coughing should hurt less
D. If you support your incision with a pillow, coughing should hurt less
A 2 day postpartum breastfeeding woman states, "I am sick of being fat. When can I go on a diet?" Which of the following responses is appropriate? A. It is time for you to start dieting right now as long as you drink plenty of milk B. Your breast milk will be low in vitamins if you start to diet while breastfeeding C. You must eat at least 3000 calories per day in order to produce enough milk for your baby D. Many mothers lose weight when they breastfeed because the baby consumes about 600 calories per day
D. Many mothers lose weight when they breastfeed because the baby consumes about 600 calories per day
A G2 P2002 who is postpartum 6 hours from a spontaneous vaginal delivery is assessed. The nurse notes that the fundus is firm at the umbilicus, there is heavy lochia rubra, and perineal sutures are intact. Which of the following actions should the nurse take at this time? A. Do nothing. This is a normal finding B. Massage the woman's fundus C. Take the woman to the bathroom to void D. Notify the woman's primary healthcare provider
D. Notify the woman's primary healthcare provider due to the heavy lochia
The nurse is preparing to place a peripad on the perineum of a client who delivered her baby 10 minutes earlier. The client states, "I don't use those. I always use tampons". Which of the following actions by the nurse is appropriate at this time? A. Remove the peripad and insert a tampon into the woman's vagina B. Advise the client that for the first two days she will be bleeding too heavily for a tampon C. Remind the client that a tampon would hurt until the soreness from the deliver resolves D. State that it is unsafe to place anything into the vagina until involution is complete
D. State that it is unsafe to place anything into the vagina until involution is complete
A client, G1 P1, who had an epidural has just delivered a daughter, Apgar 9/9, over a mediolateral episiotomy. The physician used low forceps. While recovering, the client states, "I'm a failure. I couldn't stand the pain and couldn't even push my baby out by myself!" Which of the following is the best response for the nurse to make? a. You'll feel better later after you have had a chance to rest and to eat B. dont say that. there are many women who would be ecstatic to have that baby C. I am sure that you will have another baby. I bet that it will be a natural delivery D. To have things work out differently than you had planned is disappointing.
D. To have things work out differently than you had planned is disappointing.
A client informs the nurse that she intends to bottle feed her baby. Which of the following actions should the nurse encourage the client to perform? Select all that apply. A. Increase her fluid intake for a few days B. Massage her breasts every 4 hours C. Apply heat packs to her axillae D. Wear a supportive bra 24 hours a day E. Stand with her back toward the shower water
D. Wear a supportive bra 24 hours a day E. Stand with her back toward the shower water
Maddy, a G3 P1 woman, gave birth 12 hours ago to a 9 lb. 13 oz. daughter. She experiences severe cramps with breastfeeding. The perinatal nurse best describes this condition as: a. Afterpains b. Uterine hypertonia c. Bladder hypertonia d. Rectus abdominis diastasis
a. Afterpains *Rationale:* Afterpains (afterbirth pains) are intermittent uterine contractions that occur during the process of involution. Afterpains are more pronounced in patients with decreased uterine tone due to overdistension, which is associated with multiparity and macrosomia. Patients often describe the sensation as a discomfort similar to menstrual cramps.
The nurse is providing discharge counseling to a woman who is breastfeeding her baby. The nurse advises the woman that if she experiences unilateral breast inflammation, she should do which of the following? a. Apply warm soaks to the reddened area. b. Consume an herbal galactagogue. c. Bottle feed the baby during the next day. d. Take expressed breast milk to the laboratory for analysis.
a. Apply warm soaks to the reddened area. *Rationale:* a. The client may be developing mastitis. She should apply warm soaks to the area. b. There is no need for a galactagogue. c. It is essential that the client continue to breastfeed. If she were to stop feeding, she could develop a breast abscess. d. Unless ordered by the physician, the milk need not be cultured.
A nurse is caring for a woman who is 4 hours post-cesarean birth for arrest of labor. The labor and operative records indicate that she had premature rupture of membranes followed by 36 hours of labor. Her IV fluid intake for the past 24 hours is 2500 mL. The estimated blood loss is 1500 mL. Based on this data, the woman is at risk for which of the following? (Select all that apply.) a. Fluid volume deficit b. Infection c. Impaired mother-infant attachment d. Falls
a. Fluid volume deficit b. Infection c. Impaired mother-infant attachment d. Falls *Rationale:* The woman is at risk for fluid volume deficit related to blood loss and risk for postpartum hemorrhage due to risk of uterine atony. She is at risk for infection related to premature and prolonged rupture of membranes. The woman is at risk for impaired mother-infant attachment related to maternal pain and exhaustion. She is at risk for falls related to anesthesia and orthostatic hypotension.
A woman who gave birth 2 hours ago has a temperature of 37.9°C. Select all of the immediate nursing actions. a. Have patient drink two glasses of fluid over the next hour. b. Explain to the patient that she needs to rest and assist her into a comfortable position. c. Medicate the patient with 500 mg of acetaminophen as per orders. d. Call the patient's physician or midwife to report the elevated temperature.
a. Have patient drink two glasses of fluid over the next hour. b. Explain to the patient that she needs to rest and assist her into a comfortable position. *Rationale:* A mild temperature elevation within a few hours of birth can be related to dehydration and exhaustion. Acetaminophen is given if the temperature remains elevated after the woman has been hydrated and rested. The physician or midwife is notified if temperature remains elevated after initial interventions.
The nurse is working with a 36-year-old, married client, G6 P6, who smokes. The woman states, "I don't expect to have any more kids, but I hate the thought of being sterile." Which of the following contraceptive methods would be best for the nurse to recommend to this client? a. Intrauterine device b. Contraceptive patch c. Bilateral tubal ligation d. Birth control pills
a. Intrauterine device *Rationale:* a. An intrauterine device (IUD) is an excellent contraceptive method for women who have had at least one delivery, are in a monogamous relationship, and wish to have long-term contraception. b. The contraceptive patch is not recommended for women over 35 or for women who smoke. c. A bilateral tubal ligation is a sterilization procedure. d. Birth control pills are not recommended for women over 35 or for women who smoke.
The best time to give prophylactic antibiotics to the women undergoing cesarean section is: a. One hour before the surgery b. Two hours before the surgery c. Not indicated unless she has an active infection d. At the time the cord is clamped
a. One hour before the surgery *Rationale:* Administration of narrow-spectrum prophylactic antibiotics should occur within 60 minutes prior to the skin incision.
Tanya, a 30-year-old woman, is being prepared for an elective cesarean birth. The perinatal nurse assists the anesthesiologist with the spinal block and then positions Tanya in a supine position. Tanya's blood pressure drops to 90/52, and there is a decrease in the fetal heart rate to 110 bpm. The perinatal nurse's best response is to: a. Place a wedge under Tanya's left hip. b. Discontinue Tanya's intravenous administration. c. Have naloxone (Narcan) ready for administration. d. Have epinephrine ready for administration.
a. Place a wedge under Tanya's left hip. *Rationale:* In the event of severe maternal hypotension, the nurse should place the patient in a lateral position or use a wedge under the hip to displace the uterus, elevate the legs, maintain or increase the IV infusion rate, and administer oxygen by face mask at 10 to 12 L/min, or according to institution protocol.
The perinatal nurse teaches the student nurse that deep breathing exercises following a cesarean birth are critical to the prevention of (select all that apply): a. Pneumonia b. Atelectasis c. Abdominal distension d. Increased tidal volume
a. Pneumonia b. Atelectasis *Rationale:* Incisional pain and abdominal distension often cause patients to adopt shallow breathing patterns that can lead to decreased gas exchange and a reduced tidal volume. To facilitate adequate lung functions, patients should be taught how to perform pulmonary exercises. Expectoration of secretions and deep breathing help prevent common complications including atelectasis and pneumonia. Abdominal distension and gas pains are common after abdominal surgery and result from delayed peristalsis.
The perinatal nurse is preparing a woman for a scheduled cesarean birth. The woman will be receiving spinal anesthesia for the birth. In order to prevent maternal hypotension, the nurse: a. Assists the woman to lie down in a supine position. b. Administers a rapid intravenous infusion of 500 mL of normal saline. c. Assesses blood pressure and pulse every 5 minutes, three times, before the spinal insertion. d. Encourages frequent cleansing breaths after the patient has been placed in the correct position for the anesthesia administration.
b. Administers a rapid intravenous infusion of 500 mL of normal saline. *Rationale:* Complications that may occur with spinal anesthesia block include maternal hypotension, decreased placental perfusion, and an ineffective breathing pattern. Prior to administration, the patient's fluid balance is assessed, and IV fluids are administered to reduce the potential for sympathetic blockade (decreased cardiac output that results from vasodilation with pooling of blood in the lower extremities). Following administration of the anesthetic, the patient's blood pressure, pulse, and respirations and fetal heart rate must be taken and documented every 5 to 10 minutes.
A 25 year-old woman gave birth to her second child 6 hours ago. She informs the nurse that she is bleeding more than with her previous birth experience. The initial nursing action is to: a. Explain that this is normal for second-time moms. b. Assess the location and firmness of the fundus. c. Change her pad and return in 1 hour and reassess. d. Give her 10 units of oxytocin as per standing order.
b. Assess the location and firmness of the fundus. *Rationale:* a. The nurse should not inform the patient that this is normal until she has assessed for the degree and potential cause of bleeding. b. It is important to first assess for uterine atony or displaced uterus from full bladder. c. If the uterus is firm and midline, then the nurse should change the pad and return within 30 minutes to assess the amount of lochia. d. The nurse would give oxytocin if the uterus is boggy and does not respond to uterine massage.
During change of shift report, the nurse hears the following information on a newly delivered client: 27 years old, married, G4 P3, 8 hours postspontaneous vaginal delivery over 3º laceration, vitals—110/70, 98.6ºF, 82, 18, fundus firm at umbilicus, moderate lochia, ambulated to bathroom to void three times for a total of 900 mL, breastfeeding every 2 hours. Which of the following nursing diagnoses should the nurse include in this client's nursing care plan? a. Fluid volume deficit b. Impaired skin integrity c. Impaired urinary elimination d. Ineffective breastfeeding
b. Impaired skin integrity *Rationale:* a. There is nothing in the scenario that indicates that this client has had a significant blood loss. b. The client has a 3º laceration. A nursing diagnosis of impaired skin integrity is appropriate. c. The client is voiding well. There is no indication of impaired urinary elimination. d. The client is feeding q 2 h. There is no indication of impaired breastfeeding.
Which of the following nursing actions are important in the care of a postpartum woman who is at risk for orthostatic hypotension? (Select all that apply.) a. Have patient remain in bed for the first 4 hours postbirth. b. Instruct patient to slowly rise to a standing position. c. Open an ammonia ampule and have the patient smell the ammonia prior to getting out of bed. d. Explain to the patient the cause and incidence of orthostatic hypotension.
b. Instruct patient to slowly rise to a standing position. d. Explain to the patient the cause and incidence of orthostatic hypotension. *Rationale:* Postpartum women are at risk for orthostatic hypotension during the first few hours postdelivery. Orthostatic hypotension is a sudden drop in the blood pressure when the woman stands up due to decreased vascular resistance in the pelvis. The woman should be instructed to sit on the edge of her bed for a few minutes and then slowly stand up. The nurse or aide should be with the woman the first few times she ambulates. Ammonia ampules are used when the woman faints and is not given prior to fainting.
During a cesarean section, which action by the nurse is done to prevent compression of the descending aorta and vena cava? a. Right lateral tilt b. Left lateral tilt c. Elevate head of gurney at 30 degrees d. Administration of IV fluid preload of 500 to 1000 mL
b. Left lateral tilt *Rationale:* Positioning of the patient with a left tilt maintains a left uterine displacement to decrease the risk of aortocaval compression related to compression on the aorta and inferior vena cava due to weight of the gravid uterus.
During a postpartum assessment, the nurse notes that the uterus is midline and boggy. The immediate nursing action is: a. To notify the patient's midwife or physician b. Massage the fundus until firm and reevaluate within 30 minutes c. Give Syntocinon as per orders d. Assist the patient to the bathroom and ask her to void
b. Massage the fundus until firm and reevaluate within 30 minutes *Rationale:* a. If the uterus does not respond to massage, then the nurse would give Syntocinon and notify the primary health provider. b. The first nursing action for a boggy uterus is to massage the fundus. c. If the uterus does not respond to massage, then the nurse would give Syntocinon and notify the primary health provider. d. You would assist the woman to the bathroom if the uterus is boggy and displaced to the side.
The perinatal nurse understands that the purpose of combining an opioid with a local anesthetic agent in an epidural is primarily to: a. Increase the total anesthetic volume b. Preserve a greater amount of maternal motor function c. Increase the intensity of the motor and sensory block d. Decrease the number of side effects
b. Preserve a greater amount of maternal motor function *Rationale:* Combining an opioid with a local anesthetic agent reduces the total amount of anesthetic required and helps to preserve a greater amount of maternal motor function.
A 35-year-old G1 P0 postpartum woman is Rh0(D)-negative and needs Rh0(D) immune globulin to be administered. The most appropriate dose that the perinatal nurse would expect to be ordered would be: a. 120 ug b. 250 ug c. 300 ug d. 350 ug
c. 300 ug *Rationale:* Nonsensitized women who are Rh0(D)-negative and have given birth to an Rh(D)-positive infant should receive 300 ug of Rh0(D) immune globulin (RhoGAM) within 72 hours after giving birth. RhoGAM should be given whether or not the mother received RhoGAM during the antepartum period. In some situations, depending on the extent of hemorrhage and exchange of maternal-fetal blood, a larger dose of RhoGAM may be indicated.
A nurse is preparing a woman in early labor for an urgent cesarean birth related to breech presentation. Select the best nursing action for reducing the couple's anxiety levels. a. Explain the reason for the need for a cesarean section. b. Inform parents that their baby is in distress. c. Ask the couple to share their concerns. d. Reassure the couple that both the woman and baby are in no danger.
c. Ask the couple to share their concerns. *Rationale:* a. Explaining the reason she is having a cesarean birth is helpful but may not address their concerns. b. It is important to acknowledge that the baby is stable, but this response does not allow the couple to share their concerns that may be causing an increase in anxiety. c. By asking the couple to share their concerns, the nurse can address these concerns. d. Reassuring the couple that the woman and baby are in no danger is correct, but it is not the best answer because it does not allow the couple to verbalize their concerns.
Which of the following clients is most likely to complain of afterbirth pains during her postpartum period? a. G1 P0, diagnosed with preeclampsia b. G2 P0, group B streptococci in the vagina c. G3 P2, gave birth to a 4100-gram baby d. G4 P1, diagnosed with preterm labor
c. G3 P2, gave birth to a 4100-gram baby *Rationale:* a. This client is a primipara. The nurse would not expect her to complain excessively of afterbirth pains. b. This client is a primipara. The nurse would not expect her to complain excessively of afterbirth pains. c. This client is a multipara and she delivered a macrosomic baby. She is likely to complain of severe afterbirth pains. d. Although this client is a gravida 4, she is a para 1. The nurse would not expect her to complain excessively of afterbirth pains.
Which of the following is a medical indication for a cesarean birth? (Select all that apply.) a. Maternal blood pressure of 130/90 b. Cervical dilation of 1.5 cm per hour during the active phase of labor c. Late deceleration of the fetal heart rate with minimal variability d. Complete placenta previa e. Arrest of fetal descent
c. Late deceleration of the fetal heart rate with minimal variability d. Complete placenta previa e. Arrest of fetal descent *Rationale:* A maternal blood pressure of 130/90 may be an indication of mild PHI which is not a medical indication for cesarean birth. Cervical dilation of 1.5 cm/minutes is within normal limits for cervical changes during the active phase. Late decelerations combined with minimal variability in the fetal heart rate reflect fetal intolerance of labor and are an indication for cesarean birth. A complete placenta previa covers the internal os necessitating a cesarean birth. Arrest of fetal descent indicates cephalopelvic disproportion.
Which of these medications is commonly used to control postpartum bleeding related to uterine atony? a. Magnesium sulfate b. Phytonadione c. Oxytocin d. Warfarin
c. Oxytocin *Rationale:* a. Magnesium sulfate is commonly used for PIH and preterm labor. It is a smooth muscle relaxant and can cause the uterus to relax. b. Phytonadione (vitamin K) is important for clotting but will not cause the uterus to contract. c. Oxytocin is commonly used to control postpartum bleeding related to uterine atony. d. Warfarin is an anticoagulant and will increase the risk of hemorrhage.
A nurse is performing a postpartum assessment 30 minutes after a vaginal delivery. Which of the following actions indicates that the nurse is performing the assessment correctly? a. The nurse measures the fundal height in relation to the symphysis pubis. b. The nurse monitors the client's central venous pressure. c. The nurse assesses the client's perineum for edema and ecchymoses. d. The nurse performs a sterile vaginal speculum exam.
c. The nurse assesses the client's perineum for edema and ecchymoses. *Rationale:* a. The fundal height should be measured in relation to the umbilicus. b. The central venous pressure is not monitored during postpartum assessments. c. The nurse should assess the perineum for signs of edema and ecchymoses. d. If a speculum exam were needed, a physician or midwife would perform the procedure. Speculum exams are rarely needed postpartum.
On day four following the birth of an average size baby, the nurse would expect the fundus to be at: a. 1 cm below umbilicus b. 2 cm below umbilicus c. 3 cm below umbilicus d. 4 cm below umbilicus
d. 4 cm below umbilicus *Rationale:* a. Expected location for day 1 b. Expected location for day 2 c. Expected location for day 3 d. Correct. The uterus on the average descends 1 centimeter per day.
Heather, a postpartum woman who experienced a spontaneous vaginal birth 12 hours ago, describes a headache that is worsening. Heather was given two regular strength acetaminophen (Tylenol) tablets approximately 30 minutes ago but has had no relief from the pain. Several friends and family members are presently visiting Heather. The nurse notes that Heather's pain relief during labor consisted of a single dose of an IM narcotic. The most appropriate nursing action at this time is to: a. Notify Heather's health-care provider about Heather's headache. b. Dim the lights in Heather's room so that she is able to get some rest. c. Ask Heather's visitors to leave now to decrease Heather's environmental stimuli. d. Ask Heather where she is experiencing this headache and to identify the pain score that best describes the intensity of the pain.
d. Ask Heather where she is experiencing this headache and to identify the pain score that best describes the intensity of the pain. *Rationale:* The nurse should perform routine, comprehensive pain assessments to include onset, location, intensity, quality, characteristics, and aggravating and alleviating factors of the discomfort in order to provide interventions in a timely manner and enhance effectiveness of medications. The nurse should also ask the patient to rate her pain on a standard 0 to 10 pain scale before and after interventions and to identify her own acceptable comfort level on the scale.
A client delivered a 2800-gram neonate 4 hours ago by cesarean section with epidural anesthesia. Which of the following interventions should the nurse perform on the mother at this time? a. Maintain the client flat in bed. b. Assess the client's patellar reflexes. c. Monitor hourly urinary outputs. d. Assess the client's respiratory rate.
d. Assess the client's respiratory rate. *Rationale:* a. The client should be assisted to a position of comfort. b. There is no indication in the scenario that the client must have her reflexes assessed. c. The client's hydration should be monitored postsurgery, but hourly assessments are unnecessary. d. The client has undergone major abdominal surgery. Her respiratory function should be assessed regularly.
A nurse is preparing to administer RhoGam to a client who delivered a fetal demise. Which of the following must the nurse check before giving the injection? a. Verify that the direct Coombs test results are positive. b. Check that the fetus was at least 28 weeks' gestation. c. Make sure that the client is at least 3 days postdelivery. d. Confirm that the client is Rh negative.
d. Confirm that the client is Rh negative. *Rationale:* a. The direct Coombs test is irrelevant, and because the baby has died, the Coombs will likely not be performed. b. RhoGam should be given no matter how old the fetus was. c. RhoGam must be administered before 72 hours postpartum. d. RhoGam is contraindicated for clients who are Rh+ (positive). The nurse must confirm that any client receiving RhoGam is Rh negative.
The perinatal nurse listens as Chantal describes her labor and emergency cesarean birth. Providing an opportunity to review this experience may assist Chantal in: a. Her role development in the "letting go" stage b. Decreasing her ambivalence about her labor and birth c. Understanding her guilt involved in her labor and birth d. Developing more positive feelings about her labor and birth
d. Developing more positive feelings about her labor and birth *Rationale:* After a cesarean birth, especially when unplanned, nurses must be aware of the myriad of potential psychological issues that may arise. Research suggests that women may perceive cesarean birth to be a less positive experience than a vaginal birth. Unplanned or emergent cesarean deliveries and the experience of cesarean birth may be associated with more negative perceptions of the birthing experience. Allowing Chantal to talk about the experience can help her develop a more positive attitude about her own experience.
The perinatal nurse teaches the postpartum woman about the normal process of diuresis that she can expect to occur approximately 6 to 8 hours after birth. A decrease in which of the following hormones is primarily responsible for the diuresis? a. Prolactin b. Progesterone c. Oxytocin d. Estrogen
d. Estrogen *Rationale:* Maternal diuresis occurs almost immediately after birth and urinary output reaches up to 3000 mL each day by the second to fifth postpartum days. After childbirth, a decrease in the level of estrogen naturally occurs and contributes to the diuresis.
A nurse is admitting a woman for a scheduled cesarean section. Which of the following assessment data should be immediately reported to the physician? a. White cell count of 11,000 b. Hemoglobin of 11 g/dL c. Hematocrit of 33% d. Platelet count of 97,000
d. Platelet count of 97,000 *Rationale:* Normal range of platelets is 150,000 to 400,000. A low platelet count places the woman at risk for increased bleeding.
A nurse is caring for a woman 10 hours post-cesarean birth. She received a dose of intrathecal morphine at the time of the birth. Which of the following assessment data would require immediate intervention? a. Itching of the palms and feet b. Nausea c. Urinary output of 300 mL in the past 4 hours d. Respiratory rate of 10 breaths/minute
d. Respiratory rate of 10 breaths/minute *Rationale:* a. This is a side effect of intrathecal morphine which is not life threatening. b. This is a side effect of intrathecal morphine which is not life threatening. c. A urinary output of 300 mL in 4 hours is within normal limits. d. Correct. An adverse effect of intrathecal morphine that requires immediate intervention is respiratory distress.
