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 C
Explanation
A. Establish a new routine for the child to follow while in the facility. This is incorrect because preschoolers find comfort in familiar routines. Maintaining their usual routines as much as possible helps reduce anxiety.
B. Use medical terminology when discussing procedures with the child. This is incorrect because preschoolers have a limited understanding of medical terms. Using simple, age-appropriate language helps them better comprehend what is happening.
C. Encourage the child to play with toys such as a pounding board. This is correct because preschoolers benefit from play to express emotions and relieve stress. Toys like a pounding board allow them to release frustration in a safe and developmentally appropriate way.
D. Perform the morning assessments when the parent is not in the room. This is incorrect because having a parent present provides comfort and security, which can help the child remain calm during assessments.
Correct Answer is B
Explanation
A. Hypertension is not a typical finding of hypocalcemia. Instead, hypocalcemia can cause hypotension due to decreased myocardial contractility.
B. Muscle twitching is a common manifestation of hypocalcemia. Low calcium levels increase neuromuscular excitability, leading to twitching, tetany, and spasms.
C. A bounding pulse is not associated with hypocalcemia. Instead, hypocalcemia can cause weak, thready pulses due to decreased cardiac output.
D. Increased urine output is not a direct symptom of hypocalcemia. However, hypercalcemia can lead to polyuria due to its effect on the kidneys.
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