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 A
Explanation
Choice A rationale:
Offering the parents the opportunity to bathe and dress their baby can provide a sense of normalcy and closure.
Choice B rationale:
This statement assumes the client wants to have another baby and that they will be able to do so, which may not be the case.
Choice C rationale:
It’s important to allow the parents to grieve in their own way. Some may find holding the baby helpful, while others may not.
Choice D rationale:
While naming the baby can provide an identity, it should be the parents’ decision.
Correct Answer is D
Explanation
Choice A rationale:
A 21-gauge needle is too large for a heel stick on a newborn.
Choice B rationale:
Alcohol can cause skin irritation and should not be used after the procedure.
Choice C rationale:
A warm cloth, not a cool one, should be applied to the site before the procedure to enhance circulation.
Choice D rationale:
The lateral side of the heel is the correct site for a heel stick to avoid injury to the bone.
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