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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?

A.

Report of perineal pain as 0 on a scale of 0 to 10

B.

Report of relief of pruritus

C.

Increased urinary output

D.

Blood pressure 110/70 mm Hg .

Answer and Explanation

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
Administering a 500 mL lactated Ringer’s IV bolus is not the first action to take when a nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage.
Choice B rationale
Documenting urinary output is important, but it is not the first action to take when a nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage.
Choice C rationale

Replacing the surgical dressing is not the first action to take when a nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage.
Choice D rationale
Notifying the healthcare provider is the correct action. Persistent vaginal bleeding after a cesarean birth could indicate a postpartum hemorrhage, which is a medical emergency

Correct Answer is A

Explanation

Choice A rationale
Facial petechiae are small, pinpoint, red or purple spots on the skin that result from minor bleeding from broken capillary blood vessels. They can occur as a result of a nuchal cord, which is when the umbilical cord becomes wrapped around the fetus’s neck. This can cause pressure and minor injuries, leading to the appearance of petechiae.
Choice B rationale
Periauricular papillomas are not typically associated with a nuchal cord. They are small, benign skin growths that occur near the ear. They are not a common finding in newborns and are not related to the conditions of birth.
Choice C rationale
Erythema toxicum is a common rash seen in newborns, characterized by tiny bumps surrounded by an area of red skin. It is not specifically associated with a nuchal cord.
Choice D rationale
Telangiectatic nevi, also known as “stork bites,” are common birthmarks seen in newborns, characterized by patches of pink or red skin. They are not specifically associated with a nuchal cord.

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