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
Report of relief of pruritus
Increased urinary output
Blood pressure 110/70 mm Hg .
The Correct Answer is D
Choice A rationale
The report of perineal pain as 0 on a scale of 0 to 10 is not directly related to the effectiveness of the IV bolus of lactated Ringer’s. Perineal pain is more associated with the birthing process and not with the administration of IV fluids.
Choice B rationale
Relief of pruritus is not a direct indication of the effectiveness of the IV bolus of lactated Ringer’s. Pruritus, or itching, can be a side effect of certain medications or a symptom of various conditions, but it is not typically associated with the administration of IV fluids.
Choice C rationale
While increased urinary output can be a sign of adequate hydration, it is not the primary indicator of the effectiveness of a bolus of lactated Ringer’s. Urinary output can be influenced by various factors, including kidney function and fluid intake, but a single instance of increased urinary output does not necessarily indicate that the IV bolus was effective.
Choice D rationale
The primary goal of administering a bolus of IV fluids like lactated Ringer’s in a client who is in labor and has a prescription for spinal anesthesia is to maintain or improve the client’s hemodynamic status, which includes maintaining a stable blood pressure. Therefore, a blood pressure reading of 110/70 mm Hg indicates that the IV bolus was effective.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
A pudendal nerve block is not typically used for postpartum perineal pain management. It is more commonly used during labor to relieve pain in the perineum and vagina.
Choice B rationale
While hydrogel pads can provide cooling relief, they are not typically used for third-degree perineal lacerations. These types of lacerations often require more intensive interventions.
Choice C rationale
Applying a warm pack to the perineum can help with discomfort, but it is not the primary intervention for a third-degree perineal laceration.
Choice D rationale
Witch hazel pads are often recommended for postpartum perineal care. They can provide relief from soreness, reduce inflammation, and promote healing.
Correct Answer is B
Explanation
Choice A rationale
Transient occipital cyanosis is not a clinical finding that should be reported to the provider. It is a normal finding in newborns due to immature circulation and should resolve on its own.
Choice B rationale
Single palmar creases, also known as simian lines, can be a sign of certain genetic conditions, such as Down syndrome. Therefore, this finding should be reported to the provider.
Choice C rationale
Subconjunctival hemorrhage, or a red spot in the white of the eye, is a common and harmless condition in newborns. It does not require treatment and will disappear as the blood is absorbed.
Choice D rationale
Dystocia, or difficult labor, is not a clinical finding in a newborn. It refers to a situation during childbirth where there is slow or difficult labor or delivery.
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