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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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Correct Answer is C

Explanation

Choice A rationale

Pedal edema is an assessment related to heart failure or peripheral vascular disease but is not specifically connected to the adverse effects of prasugrel, which is an antiplatelet medication that primarily affects blood clotting processes.

Choice B rationale

Measuring body temperature can help detect infections or fever, but it is not a primary assessment for the adverse effects of prasugrel. The medication's adverse effects are more closely related to bleeding risks.

Choice C rationale

Prasugrel, an antiplatelet medication, increases the risk of bleeding. Observing the color of urine can help detect hematuria, an indication of internal bleeding, making it a critical assessment for clients taking this medication.

Choice D rationale

Assessing skin turgor is generally used to evaluate hydration status, not to monitor for adverse effects of prasugrel. This assessment would not provide relevant information about bleeding risks associated with prasugrel use.

A. Explain that every client will receive the same high level of care. B. Ask the client about individual care preferences. C. Consult with a nurse who shares the same religious beliefs. D. Research the religion on different social media platforms.

Correct Answer is B

Explanation

Choice A rationale

Explaining that every client will receive the same high level of care does not address the client's specific concerns about receiving care in accordance with their religion. It is important to recognize and respect individual preferences and beliefs in healthcare.

Choice B rationale

Asking the client about individual care preferences is the best action as it allows the nurse to understand and accommodate the client's specific religious needs and preferences. This approach demonstrates respect for the client's beliefs and promotes patient-centered care.

Choice C rationale

Consulting with a nurse who shares the same religious beliefs might provide some insight, but it is not the best approach. The client may have unique personal preferences that differ from general practices of their religion, so direct communication with the client is more effective.

Choice D rationale

Researching the religion on social media platforms is not a reliable or appropriate way to gather information about a client's care preferences. Social media may not provide accurate or comprehensive information, and personal preferences should be discussed directly with the client. .

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's plan of care?

Correct Answer is C

Explanation

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

Correct Answer is B

Explanation

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

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