A nurse is caring for a client who is in active labor.

Exhibits

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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Schedule the client for an MRI after the procedure. This is incorrect because an MRI is not required following a thoracentesis. Instead, a chest X-ray may be ordered to assess for complications such as a pneumothorax.
B. Place the client leaning forward over the overbed table. This is correct because this position allows for optimal lung expansion and easier access to the pleural space for fluid removal.
C. Encourage the client to take deep breaths during the procedure. This is incorrect because the client should remain still and avoid deep breathing or coughing to prevent lung injury.
D. Ensure the client has been NPO for 6 hr. This is incorrect because NPO status is not required for a thoracentesis, as it is not a gastrointestinal or sedation-based procedure.

A. Reinsert the protruding intestinal tissue. B. Place the client in Trendelenburg position. C. Cover the wound with a saline-soaked dressing. over D. Monitor vital signs every 30 min.

Correct Answer is C

Explanation

A. Reinserting the protruding intestinal tissue is inappropriate and can cause further injury or infection. The nurse should keep the tissue moist and protected until surgical intervention.
B. Placing the client in Trendelenburg position is incorrect because it does not reduce tension on the wound. Instead, the client should be placed in a low Fowler's position with knees slightly flexed to reduce strain.
C. Covering the wound with a sterile saline-soaked dressing is the priority action to keep the tissue moist and prevent further contamination or damage until the provider can intervene.
D. Monitoring vital signs every 30 minutes is important but not the priority action. The nurse should immediately cover the wound first, then monitor for signs of shock or infection.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who is in active labor. Exhibits 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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following actions should the nurse include in the plan?

Correct Answer is B

Explanation

A nurse is caring for a client who is postoperative following abdominal surgery. The client reports feeling like "something opened up." The nurse peels back the dressing to find separation of the incision with protrusion of intestinal tissue. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client in the emergency department. Exhibits Complete the following sentence by using the list of options. The nurse should prepare to administer dropdown and dropdown

A nurse is preparing a client for a pelvic examination. Which of the following actions should the nurse take?

A nurse in an emergency department (ED) is assessing a preschooler who has a fractured arm. For which of the following should the nurse further investigate as a warning sign of child maltreatment?

A nurse is implementing crisis intervention for a client following an incident of partner violence. Which of the following is the priority action for the nurse to take?

A nurse is assessing a client who is 2 days postoperative following a transurethral resection of the prostate and has an indwelling urinary catheter in place. Which of the following findings should the nurse expect?

A nurse is teaching a client about using transdermal scopolamine to treat motion sickness. Which of the following instructions should the nurse include?

A nurse is planning postoperative care for a client who is scheduled for a thoracotomy with chest tube placement. Which of the following pieces of equipment should the nurse plan to have at the client's bedside?

A nurse is observing an assistive personnel (AP) measure blood pressures from the right arms of a group of clients. The nurse should instruct the AP to measure the blood pressure in the left arm of which of the following clients?

A nurse is caring for a client who is in active labor.

Exhibits

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.