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.
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)
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
An older client one day postoperative with a colostomy for colon cancer may have complex needs that require the expertise of an RN rather than a PN.
Choice B rationale
An older adult scheduled for foot amputation due to diabetes complications may also have complex needs and potential complications that necessitate the supervision of an RN.
Choice C rationale
An adult with alcoholism, cirrhosis, and hepatic encephalopathy is likely to have complex medical issues and require close monitoring and interventions, best suited for an RN.
Choice D rationale
An adult one day postoperative for a laparoscopic cholecystectomy is generally stable and has less complex needs, making them an appropriate assignment for a PN.
Correct Answer is ["B","F","G","H"]
Explanation
Choice B rationale: Assessing the client's pain is crucial as the client becomes more aware. Pain management is essential for comfort and recovery. As the client wakes up, they may begin to experience pain and discomfort, which should be promptly addressed.
Choice F rationale: Determining the client’s decision-making ability is important as the client wakes up to assess their cognitive status and ability to participate in their own care decisions. This helps in planning further care and interventions appropriately.
Choice G rationale: Decreasing the noise and light stimuli in the room as much as possible helps to create a calm environment, which is important for a patient recovering from trauma and surgery. It helps reduce anxiety and agitation as the client becomes more aware of their surroundings.
Choice H rationale: Explaining all procedures is essential for the client’s understanding and cooperation. Clear communication helps reduce anxiety and ensures that the client knows what to expect, which is important for their overall comfort and trust in the healthcare team.
Choice A rationale: Increasing the propofol infusion is incorrect because it is necessary to assess the client’s awareness and response to the current sedation level. Over-sedating the client can delay recovery and obscure their neurological status.
Choice C rationale: Notifying the social worker the client is awake is not immediately necessary at this stage. The focus should be on the client's medical and physical condition first.
Choice D rationale: Having the client sign consent forms for procedures already performed is inappropriate because the client may not be in a suitable mental state to provide informed consent due to recent sedation and trauma.
Choice E rationale: Considering extubating the client is premature. The decision to extubate should be based on a thorough assessment of the client’s readiness, including their ability to maintain their airway and adequate ventilation.
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