A nurse is caring for a client who is in active labor.
The nurse is caring for a client following the insertion of an epidural. For each nursing intervention, click to specify if the intervention is essential or contraindicated for the client.
Decrease the IV flow rate.
Monitor fetal heart rate
Administer ampicillin IV
Place client in left lateral position.
Request a prescription for ephedrine.
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}
Essential Interventions:
- Monitor fetal heart rate
- Administer ampicillin IV
- Place client in left lateral position
- Request a prescription for ephedrine
Contraindicated Intervention:
- Decrease the IV flow rate
Rationale:
- Monitor fetal heart rate (Essential): Epidural anesthesia can cause maternal hypotension, leading to decreased uteroplacental perfusion. Continuous fetal heart rate monitoring ensures the fetus is tolerating labor well.
- Administer ampicillin IV (Essential): The client tested positive for Group B Streptococcus (GBS) at 37 weeks, requiring prophylactic IV antibiotic administration during labor to prevent neonatal infection.
- Place client in left lateral position (Essential): This position improves venous return, enhances placental perfusion, and prevents hypotension caused by epidural anesthesia.
- Request a prescription for ephedrine (Essential): Epidural anesthesia can cause maternal hypotension, and ephedrine is a vasopressor that can help restore blood pressure if needed.
- Decrease the IV flow rate (Contraindicated): IV fluids should be maintained or increased to prevent hypotension, a common side effect of epidural anesthesia. Reducing the IV rate could exacerbate hypotension and fetal distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Reminding the AP about confidentiality is the appropriate immediate response. The nurse should provide education and reinforce HIPAA regulations to prevent future breaches.
B. Notifying the client is unnecessary and could cause undue distress. The priority is to address the behavior and prevent further violations.
C. Notifying the ethics committee is excessive for a first-time or minor violation. This step may be necessary if breaches continue despite education.
D. Filing an incident report is not required unless the breach has significant consequences. The best first step is direct education.
Correct Answer is B
Explanation
A. Allergic. Symptoms of an allergic reaction to a blood transfusion typically include itching, rash, and hives rather than chills, headache, or low-back pain.
B. Acute hemolytic. This reaction occurs when the client receives incompatible blood, leading to red blood cell destruction. Symptoms include chills, headache, low-back pain, chest tightness, hypotension, and fever.
C. Bacterial. A bacterial transfusion reaction is usually caused by contaminated blood products and presents with fever, chills, hypotension, and possible sepsis. The described symptoms suggest a different reaction.
D. Febrile nonhemolytic. This reaction is more common and presents with fever, chills, and headache but does not typically include low-back pain or chest tightness, which are more indicative of an acute hemolytic reaction.
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