Scenario:
A nurse is caring for a 26-year-old gravida 2 para 1 female client in the labor and delivery unit.

Exhibits

The client receiving epidural anesthesia would be at risk for developing

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due to

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.

Choice A rationale

A client with a positive Mantoux test and sputum cultures positive for acid-fast bacillus (AFB) requires a negative airflow room and airborne precautions. This is to prevent the spread of tuberculosis (TB), an infectious disease that can be transmitted through airborne particles. The use of a particulate respirator mask by healthcare personnel is essential in protecting themselves from inhaling infectious aerosols. Implementing these precautions is critical in controlling the spread of TB within healthcare settings and ensuring patient and staff safety.

Choice B rationale

A client with genital herpes simplex II lesions does not require a negative airflow room or airborne precautions. Herpes simplex virus (HSV) is primarily transmitted through direct contact with infected lesions or body fluids. Standard precautions, including contact precautions when dealing with lesions, are adequate to prevent the spread of HSV. Negative airflow rooms and airborne precautions are not necessary for managing this condition.

Choice C rationale

Scarlet fever, complicated with pneumonia, primarily requires standard and droplet precautions rather than airborne precautions. Scarlet fever is caused by group A Streptococcus, which is spread through respiratory droplets. While pneumonia can increase the severity of the infection, negative airflow rooms and particulate respirators are not typically required. Droplet precautions, such as wearing masks and maintaining distance, are sufficient to prevent transmission.

Choice D rationale

Scabies is a parasitic infestation that spreads through direct skin-to-skin contact or contact with contaminated items such as bedding and clothing. Negative airflow rooms and airborne precautions are not necessary for managing scabies. Standard and contact precautions, including wearing gloves and gowns and thoroughly cleaning and disinfecting contaminated items, are adequate to prevent the spread of the mites causing scabies. The use of a particulate respirator mask is not required.

Choice A rationale: Hemoglobin of 9.3 g/dL indicates that the client has anemia, likely due to blood loss from the injury. This low hemoglobin level suggests significant bleeding, which needs to be addressed to ensure adequate oxygen delivery to tissues during surgery.

Choice B rationale: Prothrombin time of 11.5 seconds is within the normal range and does not indicate a critical issue that needs to be addressed before surgery. It suggests that the client's blood clotting mechanism is functioning properly.

Choice C rationale: Blood pressure of 90/48 mm Hg indicates hypotension, which is a sign of shock or significant blood loss. It is critical to stabilize the client's blood pressure to ensure adequate perfusion to vital organs during surgery.

Choice D rationale: Heart rate of 110 beats/minute is elevated, which may be a response to pain, anxiety, or hypovolemia. While it is important to monitor, it is not as critical as addressing the hypotension and anemia before surgery.

Choice E rationale: Abdominal distention indicates potential internal bleeding or injury to abdominal organs. This needs to be addressed urgently, as it can lead to further complications and affect the outcome of the surgery.