A nurse is administering a 500 mL bolus of lactated Ringer's for a client who is in labor and has a prescription for spinal anesthesia. Which of the following findings indicates that the IV bolus was effective?
Report of perineal pain as 0 on a scale of 0 to 10.
Increased urinary output.
Blood pressure 110/70 mm Hg.
Report of relief of pruritus.
The Correct Answer is C
Choice A rationale:
Report of perineal pain as 0 on a scale of 0 to 10 is not an indication that the IV bolus was effective. It could be related to the spinal anesthesia, not the IV fluid administration.
Choice B rationale:
Increased urinary output is not a direct indication that the IV bolus was effective. It could be related to other factors such as fluid balance or kidney function.
Choice C rationale:
A blood pressure of 110/70 mm Hg is within the normal range and indicates that the IV bolus was effective in preventing hypotension, which can occur with spinal anesthesia.
Choice D rationale:
Report of relief of pruritus is not an indication that the IV bolus was effective. It could be related to other factors such as medication administration or resolution of an allergic reaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Replacing the infant’s identification band after his name has been recorded is not a recommended practice for newborn identification.
Choice B rationale:
Checking the newborn’s identification using the crib card is not a recommended practice for newborn identification.
Choice C rationale:
Obtaining an imprint of the infant’s feet prior to taking him to the nursery is a reliable method of identification of the newborn.
Choice D rationale:
Requiring visitors to wear an identification band is not a recommended practice for newborn identification.
Correct Answer is ["D","E","H"]
Explanation
Choice A rationale:
BUN is within the normal range (10 to 20 mg/dL), so it's not an indication of a potential complication.
Choice B rationale:
Potassium is slightly below the normal range (3.5 to 5 mEq/L), indicating potential hypokalemia, which can be a complication.
Choice C rationale:
Hct is at the upper limit of the normal range (33% to 49%), but still within normal, so it's not a complication.
Choice D rationale:
Weight loss of 2 kg in 1 month during pregnancy is concerning and could indicate a complication such as hyperemesis gravidarum.
Choice E rationale:
Heart rate is slightly elevated, which could indicate dehydration, a potential complication.
Choice F rationale:
Sodium is slightly below the normal range (136 to 145 mEq/L), but this alone is not typically a complication of pregnancy.
Choice G rationale:
Hgb is within the normal range (11 to 16 g/dL), so it's not a complication.
Choice H rationale:
Urine-specific gravity is above the normal range (1.005 to 1.030), indicating potential dehydration, a complication.
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