The nurse is caring for a laboring client who is requesting an epidural.
As the nurse prepares to start an IV, the client asks why it is necessary.
What would be the nurse’s best response?
“You won’t be able to eat, and this provides nutrition to you and the baby during childbirth.”
“Don’t worry about the IV, I have placed many IVs before.”
“The IV is in place to give the medication for relaxation before the epidural is placed.”
“The IV bolus will help to minimize the side effects of the epidural.”
The Correct Answer is C
Choice A rationale:
It is true that a laboring client may not be able to eat, but this is not the primary reason for starting an IV. The client can receive fluids and electrolytes through the IV to maintain hydration and energy levels.
However, this response does not directly address the client's question about why the IV is necessary for the epidural.
It's important to provide a clear and accurate explanation to help the client understand the purpose of the intervention.
Choice B rationale:
This response is dismissive of the client's concerns and does not provide any information about why the IV is necessary.
It's important to acknowledge the client's concerns and provide them with the information they need to make informed decisions about their care.
Choice C rationale:
This is the correct response. The IV is necessary to administer medication for relaxation before the epidural is placed.
The epidural is a regional anesthetic that blocks pain signals from the lower body.
The medication for relaxation helps to reduce anxiety and discomfort, which can make it easier to place the epidural.
It also helps to prevent the client from moving during the procedure, which could lead to complications.
Choice D rationale:
This response is not accurate. An IV bolus is not typically given to minimize the side effects of the epidural.
Side effects of the epidural, such as hypotension and nausea, are usually managed with other medications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
This statement is incorrect. The risk factor for a genetic disorder can vary depending on the specific disorder and the family history. For example, the risk of having a child with an autosomal recessive disorder is higher if there is a history of the disorder in the family.
Additionally, some genetic disorders have a higher risk of recurrence than others. For example, the risk of having a child with cystic fibrosis is 25% if both parents are carriers of the gene.
It's crucial for nurses to be aware of the varying risk factors associated with different genetic disorders to provide accurate information and counseling to families.
Choice C rationale:
This statement is also incorrect. The risk of a disorder involving maternal ingestion of drugs being repeated in the second child depends on several factors, including the specific drug, the dose, and the timing of exposure.
It cannot be generalized to a one in four chance for all drug-related disorders. Nurses should consult with appropriate resources and specialists to determine the specific risks associated with different drugs and exposures.
Choice D rationale:
This statement is incorrect for autosomal dominant disorders. With an autosomal dominant disorder, the likelihood of the second child also having the condition is 50%, not 100%. Each child has a 50% chance of inheriting the affected gene from the affected parent.
It's essential for nurses to understand the inheritance patterns of different genetic disorders to provide accurate information and support to families.
Choice B rationale:
This statement is correct. An autosomal recessive disease carries a one in eight risk of the second child also having the disorder. This is because both parents must be carriers of the affected gene for a child to inherit the disorder.
If both parents are carriers, there is a 25% chance that each child will inherit two copies of the affected gene and have the disorder. However, there is also a 50% chance that each child will inherit only one copy of the affected gene and be a carrier, and a 25% chance that each child will inherit two normal copies of the gene and not be affected.
Correct Answer is A
Explanation
Choice A rationale:
Diagnosing a fetus with a genetic disorder is outside the scope of practice for nurses. This task requires specialized training and expertise in genetics and diagnostic procedures, typically held by physicians such as geneticists, maternal-fetal medicine specialists, or genetic counselors.
Nurses play a crucial role in genetic counseling, but their responsibilities focus on:
Educating patients about genetic risks and testing options.
Obtaining informed consent for genetic testing.
Coordinating genetic testing appointments and procedures.
Providing emotional support and counseling to patients and families.
Facilitating communication between patients, families, and other healthcare providers.
Advocating for patients' rights and needs.
Choice B rationale:
Providing emotional support is a core component of nursing care, including genetic counseling. Nurses are trained to provide empathetic and compassionate support to patients and families who are facing the challenges of genetic conditions. This includes:
Active listening and validation of feelings.
Assisting with coping mechanisms and stress management.
Connecting patients with support groups and resources.
Promoting resilience and hope.
Choice C rationale:
Identifying at-risk families is a vital role for nurses in genetic counseling. By recognizing families with a history of genetic disorders or those who exhibit risk factors, nurses can initiate early intervention and preventive measures. This includes:
Taking a thorough family history.
Assessing risk factors and potential genetic concerns.
Educating families about their potential risks.
Referring families for genetic counseling and testing as appropriate.
Choice D rationale:
Collaboration with other healthcare providers and referral for specialized care are essential aspects of genetic counseling. Nurses often work within interdisciplinary teams to provide comprehensive care for patients with genetic concerns. This includes:
Communicating with geneticists, genetic counselors, and other specialists.
Coordinating referrals for genetic testing, counseling, and treatment.
Ensuring continuity of care across different healthcare settings.
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