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.
Monitor fetal heart rate.
Place client in left lateral position.
Administer ampicillin IV.
Request a prescription for ephedrine.
Decrease the IV flow rate.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}
- Monitor fetal heart rate: After epidural placement, continuous fetal heart monitoring is essential due to the risk of uteroplacental hypoperfusion from maternal hypotension, which can alter fetal oxygenation and variability.
- Place client in left lateral position: This position improves uterine perfusion and prevents vena cava compression, which is especially critical post-epidural to stabilize maternal blood pressure and enhance fetal oxygenation.
- Administer ampicillin IV: The client tested positive for group B Streptococcus, which requires IV prophylactic antibiotics during labor to prevent neonatal sepsis, making this an essential intervention.
- Request a prescription for ephedrine: Ephedrine may be required to manage maternal hypotension, a common adverse effect of epidural anesthesia. Early signs like fetal heart rate changes warrant readiness to intervene.
- Decrease the IV flow rate: Reducing IV fluids post-epidural can worsen hypotension and compromise placental perfusion. Instead, increasing fluids is preferred to support circulating volume and maintain BP.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Autonomy:By honoring the client’s decision to stop curative treatment and transition to hospice care, the case manager is respecting the client’s right to make informed choices about their own healthcare. Autonomy emphasizes individual control over personal decisions.
B. Distributive justice:This principle involves the fair allocation of healthcare resources across populations. While important, it is not directly related to supporting an individual’s choice to end treatment and receive hospice care.
C. Veracity:Veracity refers to truthfulness in communication between healthcare professionals and clients. Although important, it is not the primary principle demonstrated when respecting a client’s decision regarding treatment options.
D. Fidelity:Fidelity is the duty to remain loyal and keep promises, including maintaining confidentiality and being faithful to one’s role. While this principle underlies all patient interactions, it is not the central concept in honoring a client’s treatment decision.
Correct Answer is ["10"]
Explanation
Calculation:
- Determine the concentration of heparin in the solution.
Total units of heparin = 25,000 units
Total volume of solution = 250 mL
Concentration = 25,000 units / 250 mL
= 100 units/mL.
- Calculate the infusion rate in milliliters per hour (mL/hr).
Desired infusion rate = 1,000 units/hr
Infusion rate (mL/hr) = Desired infusion rate (units/hr) / Concentration (units/mL)
= 1,000 units/hr / 100 units/mL
= 10 mL/hr.
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