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 A
Explanation
Choice A rationale:
Amniocentesis is the most reliable and direct method to assess fetal lung maturity. It involves the extraction of a small sample of amniotic fluid from the amniotic sac, which surrounds the fetus in the uterus. This fluid contains various substances, including surfactant, which is a crucial substance produced by the fetal lungs that enables them to expand and function properly after birth.
By analyzing the levels of surfactant and other components in the amniotic fluid, clinicians can accurately determine the maturity of the fetal lungs. This information is essential in guiding decisions about potential delivery options, especially in cases of preterm labor or other complications that may necessitate early delivery.
Amniocentesis is generally considered a safe procedure, but it does carry some small risks, such as infection, bleeding, or amniotic fluid leakage. However, these risks are typically outweighed by the benefits of obtaining accurate information about fetal lung maturity when necessary.
Choice B rationale:
Fetal fibronectin (fFN) is a protein that is found in the amniotic fluid and cervicovaginal secretions. Elevated levels of fFN in cervicovaginal secretions between 22 and 34 weeks of gestation can indicate an increased risk of preterm labor.
However, fFN testing is not a direct measure of fetal lung maturity. It is used primarily as a screening tool to assess the risk of preterm birth, not to determine the readiness of the fetal lungs for delivery.
Choice C rationale:
Chorionic villus sampling (CVS) is a prenatal diagnostic test that involves taking a small sample of chorionic villi, which are tiny finger-like projections of placental tissue. This test is typically performed earlier in pregnancy (between 10 and 13 weeks gestation) to diagnose genetic abnormalities in the fetus.
CVS is not used to assess fetal lung maturity. It does not provide any information about the development of the fetal lungs or their readiness for birth.
Choice D rationale:
Alpha-fetoprotein (AFP) is a protein produced by the fetal liver. Elevated levels of AFP in the maternal blood can indicate an increased risk of certain birth defects, such as neural tube defects.
AFP testing is not used to assess fetal lung maturity. It does not provide any information about the development of the fetal lungs or their readiness for birth.
Correct Answer is A
Explanation
Choice A rationale:
Restriction of movement is not a necessary requirement following IV opioid administration during labor. While some healthcare providers may encourage laboring individuals to rest after receiving pain medication, it is not mandatory to remain in bed.
In fact, remaining upright and mobile can often be beneficial during labor. Movement can help encourage fetal descent, improve circulation, and potentially even shorten labor duration.
It's essential to educate clients about the benefits of staying active during labor, even after receiving pain medication. This can empower them to make informed choices about their comfort and positioning during the birthing process.
Choice B rationale:
This statement is accurate. IV opioids can cross the placenta and potentially affect the fetal heart rate.
It's crucial for clients to be aware of this potential effect so that they can understand the importance of fetal monitoring during labor. Healthcare providers will closely monitor the baby's heart rate to ensure it remains within a normal range.
Choice C rationale:
This statement is also accurate. If a baby is born too soon after the mother receives IV opioids, there is a risk of respiratory depression.
This is because the opioids can cross the placenta and affect the baby's breathing. Healthcare providers are trained to manage this risk and will take appropriate measures to ensure the baby's well-being, such as providing respiratory support if needed.
Choice D rationale:
This statement is correct. IV opioids are primarily used to relieve pain during labor, not to decrease the frequency of contractions.
While they may have some mild effects on contraction strength or duration, their primary purpose is to provide pain relief. It's important for clients to understand this distinction so that they have realistic expectations about the medication's effects.
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