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 C
Explanation
Choice A rationale
Instructing the client to avoid urinary elimination until after administration is not necessary. The administration of dinoprostone does not interfere with the client’s ability to urinate.
Therefore, this action is not required.
Choice B rationale
Placing the client in a semi-Fowler’s position for 1 hr after administration is not a necessary action. While positioning can be important in certain medical procedures, there is no specific requirement for a semi-Fowler’s position in the administration of dinoprostone.
Choice C rationale
Verifying that informed consent is obtained prior to administration is a crucial step in any medical procedure, including the administration of dinoprostone. Informed consent ensures that the client is aware of the procedure, its purpose, and any potential risks or benefits. It is a legal and ethical requirement.
Choice D rationale
Allowing the medication to reach room temperature prior to administration is not a necessary action. There is no specific requirement for dinoprostone to be at room temperature before administration.
Correct Answer is C
Explanation
Choice A rationale
Raw carrots do not contain vitamin B12. Vitamin B12 is not naturally found in plant foods.
Choice B rationale
Fresh citrus fruits do not contain vitamin B12. Vitamin B12 is not naturally found in plant foods.
Choice C rationale
This is the correct answer. Fortified soy milk is a good source of vitamin B12 for vegans. Many brands of soy milk are fortified with vitamin B12 and other nutrients to help vegans meet their nutritional needs.
Choice D rationale
Brown rice does not contain vitamin B12. Vitamin B12 is not naturally found in plant foods.
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