Try Naxlex NCLEX-RN (Free-Trial)

Scenario

A nurse is caring for a 26-year-old gravida 2 para 1 female client in the labor and delivery unit. The client delivered vaginally three years ago under epidural anesthesia. She is now in active labor and has been admitted for monitoring and pain management.

Exhibits
Click to highlight the findings that indicate the client is progressing and ready for an epidural. Select three findings which indicate that this client is ready for epidural anesthesia.

Active labor with moderate contractions

Pain reported as 7/10 on a numeric pain scale

Membranes are intact

Fetal heart rate is reactive with moderate variability

IV line has been initiated

Blood pressure is 130/80 mmHg

Temperature is 99.0°F (37.2°C)

Answer and Explanation

Correct Answer : A,B,D

Choice A rationale: Active labor with moderate contractions indicates that the cervix is dilating and the client is progressing in labor. It signifies that the client is experiencing significant pain and discomfort, making her a candidate for epidural anesthesia for pain relief.

Choice B rationale: Pain reported as 7/10 on a numeric pain scale indicates that the client is experiencing severe pain. Epidural anesthesia is effective in managing severe labor pain and improving the client's comfort during the birthing process.

Choice C rationale: Membranes are intact does not indicate that the client is ready for epidural anesthesia. The status of the membranes does not affect the timing of administering epidural anesthesia.

Choice D rationale: Fetal heart rate is reactive with moderate variability indicates that the fetus is in good condition and tolerating labor well. Epidural anesthesia can be safely administered when fetal monitoring shows reassuring signs.

Choice E rationale: IV line has been initiated is a necessary step for administering epidural anesthesia, but it does not alone indicate that the client is ready for the procedure. Other indicators of labor progression are needed.

Choice F rationale: Blood pressure is 130/80 mmHg indicates that the client's blood pressure is within normal limits. While it's important to have stable vital signs before administering an epidural, this alone does not indicate readiness for the procedure.

Choice G rationale: Temperature is 99.0°F (37.2°C) is within the normal range and does not affect the timing of administering epidural anesthesia. Temperature monitoring is important, but it is not a primary factor in determining readiness for an epidural.

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

Choice A rationale

Advancing from clear liquids as tolerated is important for the patient’s nutritional intake and postoperative recovery. However, it is not the most urgent task upon admission from the PACU. The nurse must first address immediate needs such as infection prevention and monitoring vital signs before considering dietary advancements. This step can be implemented once the patient’s initial postoperative stability is confirmed.

Choice B rationale

Administering cefazolin 1 gram IV every 6 hours is critical for preventing postoperative infections, especially in patients with surgical wounds. Prophylactic antibiotics are essential in reducing the risk of surgical site infections, which can lead to severe complications. Timely administration of antibiotics helps maintain therapeutic levels in the bloodstream, providing effective coverage against potential pathogens and promoting a positive postoperative outcome.

Choice C rationale

Straight catheterization if unable to void is important for managing urinary retention and preventing bladder distention. However, this intervention should be based on the patient’s condition and the amount of time since the last voiding. It is not the most urgent action upon admission from the PACU unless the patient is exhibiting signs of significant discomfort or bladder distention. Monitoring the patient’s urinary output is important but should follow the administration of prophylactic antibiotics.

Choice D rationale

Completing a blood cell count (CBC) in the morning is important for assessing the patient’s overall health and detecting any potential complications such as anemia or infection. However, it is not the most urgent action upon admission from the PACU. The nurse should prioritize tasks that address immediate postoperative needs, such as administering antibiotics and monitoring vital signs, before scheduling routine blood tests.

Correct Answer is ["0.75"]

Explanation

Step 1 is 0.1875 mg ÷ 0.25 mg/mL Step 2 is 0.75 mL Final answer: 0.75 mL.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

Correct Answer is B

Explanation

Correct Answer is ["0.75"]

Explanation

A client with metastatic bone cancer is requesting pain medication. Which approach should the nurse use to assess the quality of the client's pain?

The nurse is completing the admission assessment of a client with multiple sclerosis (MS). Which finding(s) should be reported to the healthcare provider immediately? Select all that apply.

The nurse recognizes that findings consistent with elder mistreatment.

A client expresses concern about receiving proper care in accordance with the client's religion. Which action is best for the nurse to take?

The nurse observes an unlicensed assistive personnel (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

A nurse is caring for an 84-year-old female client in her home and is discussing caregiver stress with the client’s daughter. Exhibits Select the 3 statements that the nurse should include when discussing caregiver stress with the client’s daughter.