A nurse is caring for a client who is in labor and just received epidural anaesthesia. The client’s blood pressure is 90/50 mm Hg. Which of the following actions should the nurse take?

Turn the client onto their side

Initiate an amnioinfusion for the client

Administer naloxone to the client

Monitor the client’s blood pressure every 15 min

Answer and Explanation

The Correct Answer is A

A common side eﬀect of epidural anaesthesia is a drop in blood pressure. Turning the client onto their side can help improve blood ﬂow to the uterus and baby and may help raise the mother’s blood pressure.

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Correct Answer is D

Explanation

Cytomegalovirus (CMV) is a common virus that can cause serious health problems in newborns if the mother acquires a primary infection during pregnancy and passes the virus to the developing fetus. CMV can be transmited transplacentally or during delivery through contact with infected body ﬂuids.

Newborns who acquire CMV transplacentally may exhibit a range of symptoms, including jaundice, hepatosplenomegaly, thrombocytopenia, microcephaly, and hearing loss. Of the options listed, only hearing loss is consistent with a congenital CMV infection.

Macrosomia (option a) refers to a condition in which a baby is born larger than average for gestational age. It is not typically associated with a congenital CMV infection.

Cataracts (option b) are a clouding of the lens of the eye and are not typically associated with a congenital CMV infection.

Urinary tract infection (option c) is a possible complication of a congenital CMV infection, but hearing loss is a more common and specific finding.

A. “Your partner will apply pressure to the top of your uterus during contractions.” B. “Your partner will apply steady pressure with a tennis ball to your lower back.” C. “Your partner will apply continuous, firm pressure between your thumb and index finger.” D. “Your partner will apply upward pressure on your lower abdomen between contractions.”

Correct Answer is B

Explanation

Counterpressure is a technique that involves applying pressure to specific areas of the body during labor to help alleviate pain and discomfort. This technique is particularly helpful during the active phase of labor when contractions are strong and painful. The most common area to apply counterpressure is the lower back, as this is where many women experience the most intense pain during labor.

Option A “Your partner will apply pressure to the top of your uterus during contractions” is incorrect as applying pressure to the top of the uterus is not a recommended technique and could be harmful to the mother and the baby.

Option C “Your partner will apply continuous, firm pressure between your thumb and index finger” is incorrect as this technique is used to alleviate pain and discomfort during contractions in the hand and wrist, not for counterpressure.

Option D “Your partner will apply upward pressure on your lower abdomen between contractions” is incorrect as this technique is used to help turn a baby who is in a posterior position, not for counterpressure.

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A nurse is caring for a client who is in labor and just received epidural anaesthesia. The client’s blood pressure is 90/50 mm Hg. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn whose mother had a primary cytomegalovirus (CMV) infection during pregnancy. The newborn acquired CMV transplacentally. Which of the following findings should the nurse expect the newborn to exhibit?

Correct Answer is D

Explanation

A nurse is teaching a client and her partner about the technique of counterpressure during labor. Which of the following statements by the nurse is appropriate?

Correct Answer is B

Explanation

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A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify that which of the following factors places the client at risk for an infection?

A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions should the nurse include in the plan of care?

A nurse is caring for a client who is in labor and just received epidural anaesthesia. The client’s blood pressure is 90/50 mm Hg. Which of the following actions should the nurse take?