A nurse in an antepartum unit is caring for a client.
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Nurses' Notes
2230:
Contractions occurring every 2.5 to 3 minutes, lasting 60 to 70 seconds. Epidural placed by anesthesiologist. Client rates pain with contractions as a 3 on a scale of 0 to 10. FHR 150/min with moderate variability. Accelerations present, no decelerations noted.
Vital Signs
2230:
Temperature 38° C (100.4° F)
Heart rate 88/min
Respiratory rate 16/min
Blood pressure 122/80 mm Hg
Oxygen saturation 98% on room air
Client rates pain with contractions as a 3 on a scale of 0 to 10
FHR 150/min with moderate variability. Accelerations present, no decelerations noted
Heart rate 88/min
Respiratory rate 16/min
Blood pressure 122/80 mm Hg
Oxygen saturation 98% on room air
The Correct Answer is ["A","B","C","D","E"]
- Heart rate decreased from 104/min to 88/min, indicating improved hemodynamic stability.
- Respiratory rate decreased from 20/min to 16/min, suggesting relaxation and reduced distress.
- Blood pressure slightly decreased from 132/84 mm Hg to 122/80 mm Hg, indicating improved comfort and reduced pain-related stress response.
- Pain level decreased to 3/10 after epidural placement, demonstrating effective pain management.
- FHR 150/min with moderate variability and accelerations present, no decelerations, indicating fetal well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Simply documenting the client's lack of understanding does not address their immediate need for clarification. The nurse must take action.
B. The provider is responsible for obtaining informed consent and ensuring the client understands the procedure. The nurse should notify the provider so they can provide the necessary explanation.
C. Discussing other treatment options is beyond the nurse’s scope of practice. Only the provider should discuss alternative treatments.
D. The nurse can reinforce teaching but cannot provide new information about the surgery. Since the client is unsure about the procedure, the provider must explain it.
Correct Answer is C
Explanation
A. Have the client hold their breath during the examination. This is not recommended, as slow, deep breathing helps the client relax and reduces discomfort.
B. Ensure that the client's bladder is full. The bladder should be emptied before the exam to enhance comfort and allow better access for the provider.
C. Instruct the client to bear down when the speculum is inserted. This helps relax the pelvic muscles and makes insertion easier, reducing discomfort.
D. Place the client in modified Sims' position. The lithotomy position is the correct positioning for a pelvic examination, not modified Sims'.
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