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
The postpartum period is characterized by leukocytosis, where WBC counts can rise to 30,000/mm³ due to physiological stress. A WBC count of 15,000/mm³ is within the expected range for this client.
Choice B rationale
Perineal hematomas are more likely to cause localized pain and swelling than systemic symptoms. The assessment of perineal area is important but not the first priority in this context.
Choice C rationale
Monitoring temperature, heart rate, and respirations is crucial to identify infection but checking the differential to confirm normal physiological response to postpartum is prioritized first.
Choice D rationale
Notifying the HCP for an elevated WBC count without additional signs of infection is premature. A WBC count of 15,000/mm³ alone is not indicative of an infection in postpartum clients.
Correct Answer is C
Explanation
Choice A rationale
Administering the rubella vaccine after 20-weeks gestation is inappropriate as it is a live vaccine, which poses potential risks to the fetus. The vaccine is contraindicated during pregnancy due to teratogenic effects.
Choice B rationale
Administering the rubella vaccine at 6-weeks gestation is contraindicated because it is a live vaccine. Live vaccines pose risks to the fetus and are not recommended during pregnancy due to potential teratogenicity.
Choice C rationale
Administering the rubella vaccine early postpartum within 72 hours after delivery is recommended. This timing ensures the mother is not pregnant and reduces the risk of congenital rubella syndrome in future pregnancies.
Choice D rationale
Waiting until the client stops breastfeeding is unnecessary. The rubella vaccine can be safely administered during breastfeeding, as it does not pose a risk to the infant or affect milk production.
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