A nurse is administering a 500 mL bolus of lactated Ringer's for a client who is in labor and has a prescription for spinal anesthesia. Which of the following findings indicates that the IV bolus was effective?

Report of perineal pain as 0 on a scale of 0 to 10.

Increased urinary output.

Blood pressure 110/70 mm Hg.

Report of relief of pruritus.

Answer and Explanation

The Correct Answer is C

Choice A rationale:
Report of perineal pain as 0 on a scale of 0 to 10 is not an indication that the IV bolus was effective. It could be related to the spinal anesthesia, not the IV fluid administration.
Choice B rationale:
Increased urinary output is not a direct indication that the IV bolus was effective. It could be related to other factors such as fluid balance or kidney function.
Choice C rationale:
A blood pressure of 110/70 mm Hg is within the normal range and indicates that the IV bolus was effective in preventing hypotension, which can occur with spinal anesthesia.
Choice D rationale:
Report of relief of pruritus is not an indication that the IV bolus was effective. It could be related to other factors such as medication administration or resolution of an allergic reaction.

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Correct Answer is A

Explanation

Nägele’s Rule is a standard way of calculating the due date for a pregnancy. The rule estimates the expected date of delivery (EDD) by adding one year, subtracting three months, and adding seven days to the first day of a woman’s last menstrual period (LMP).

So, if the last menstrual cycle started on June 21, here’s how you calculate:

Subtract 3 months from June 21, which gives you March 21.
Add 7 days to March 21, which gives you March 28.
Add 1 year to the current year.

So, the estimated date of delivery in the next year would beMarch 28.

A. Decrease the rate of IV fluids. B. Perform fetal scalp stimulation. C. Administer oxygen via a face mask. D. Elevate the client's head.

Correct Answer is C

Explanation

Choice Arationale:
Decreasing the rate of IV fluids would not address the issue of late decelerations, which indicate fetal hypoxia.

Choice Brationale:
Fetal scalp stimulation is used to assess fetal well-being, but it would not address the issue of late decelerations.
Choice C rationale:
Administering oxygen via a face mask can increase the amount of oxygen available to the fetus, potentially alleviating the hypoxia causing the late decelerations.
Choice D rationale:
Elevating the client’s head would not address the issue of late decelerations.

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A nurse is administering a 500 mL bolus of lactated Ringer's for a client who is in labor and has a prescription for spinal anesthesia. Which of the following findings indicates that the IV bolus was effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is calculating the estimated date of birth using Nägele's rule for a client who is pregnant and whose last menstrual cycle started June 21. Which of the following is the estimated date of delivery in the next year?

Correct Answer is A

Explanation

A nurse is caring for a client who is in labor. The nurse observes late decelerations of the fetal heart rate on the external fetal monitor. After placing the client in a side-lying position, which of the following actions should the nurse take?

Correct Answer is C

Explanation

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A nurse is administering a 500 mL bolus of lactated Ringer's for a client who is in labor and has a prescription for spinal anesthesia. Which of the following findings indicates that the IV bolus was effective?

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