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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Visualization of implantation by vaginal ultrasound offers the highest accuracy in confirming pregnancy, as it directly visualizes the implanted embryo, eliminating errors associated with biochemical tests.
Choice B rationale
Maternal blood serum tests positive for alpha-fetoprotein do not confirm pregnancy. Alpha-fetoprotein is a marker used primarily for screening fetal abnormalities, not pregnancy determination.
Choice C rationale
The presence of amenorrhea for 2 months can suggest pregnancy but is not definitive due to other potential causes of missed periods, such as hormonal imbalances or stress, reducing its accuracy.
Choice D rationale
Reporting feeling tired all the time is a nonspecific symptom that can result from numerous conditions unrelated to pregnancy, making it an unreliable method for pregnancy determination.
Correct Answer is C
Explanation
Choice A rationale
Glucose water may be soothing due to the sweet taste, but it does not address the immediate need to protect the circumcision site from infection and aid in healing.
Choice B rationale
Liquid acetaminophen provides pain relief, but it does not address the immediate need to protect the circumcision site. Pain management alone is not sufficient for postoperative care.
Choice C rationale
Applying petrolatum gauze dressings on the site prevents the wound from sticking to the diaper, reduces irritation, and protects against infection, promoting healing. This is a priority intervention post-circumcision.
Choice D rationale
While keeping the infant warm is important for comfort and stability, it does not directly address the need to care for the circumcision site to prevent complications and promote healing.
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