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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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","B","E"]

Explanation

Choice A rationale: Involving the mother in the decision-making process can help reduce caregiver stress by sharing the responsibility and ensuring that the client's preferences and needs are considered. This collaborative approach can lead to better outcomes and improved communication.

Choice B rationale: It is important to acknowledge that caregiving can be challenging and can affect emotions. Recognizing that it is okay to have complex feelings, including not always loving or liking the person being cared for, helps normalize these emotions and reduces guilt and stress.

Choice C rationale: Moving a loved one into a care facility can be a difficult decision, but it does not necessarily mean a lack of love. However, this statement is not appropriate as it may reinforce negative emotions and guilt.

Choice D rationale: Avoiding the discussion of negative situations that may occur in the future is not helpful. It is important to plan for potential challenges to be prepared and reduce stress.

Choice E rationale: Saying "no" to things involving the care of a loved one is not selfish. It is important to set boundaries and prioritize self-care to prevent caregiver burnout. However, this statement suggests the opposite and is not appropriate.

Choice F rationale: Taking time for oneself and maintaining other important relationships is essential for a caregiver's well-being. Self-care and social support can help reduce stress and improve the ability to provide care effectively.

A. Note date and time of the behavior. B. Evaluate the UAP for signs of improvement. C. Plan for scheduled break times.

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

Noting the date and time of the behavior is the first step in addressing the issue, providing a record for future reference and ensuring accuracy in documentation.

Choice C rationale

Planning for scheduled break times helps address potential reasons for the behavior, offering a structured solution to prevent recurrence and improve overall workflow.

Choice B rationale

Evaluating the UAP for signs of improvement is the final step, assessing whether the implemented interventions have been effective and if further actions are needed.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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.

Correct Answer is ["A","B","E"]

Explanation

An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UAP's behavior? (Place the actions in order from first on top to last on bottom.)

Correct Answer is ["A","B","C"]

Explanation

The nurse is providing education to a client who receives a prescription for zolpidem. Which information about the medication should the nurse include?

A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

The healthcare provider (HCP) prescribes 0.99% normal saline 500 mL IV bolus to be infused over 30 minutes. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only) .

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?

The nurse is caring for a client who has a history of experiencing delusions. The client describes singing in a concert in the afternoon for thousands of people. Which action should the nurse take?

A nurse is caring for an 84-year-old female client in her home to establish home health care and perform an initial assessment. Exhibits Which intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.