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 D

Explanation

Choice A rationale:
A 21-gauge needle is too large for a heel stick on a newborn.
Choice B rationale:
Alcohol can cause skin irritation and should not be used after the procedure.
Choice C rationale:
A warm cloth, not a cool one, should be applied to the site before the procedure to enhance circulation.
Choice D rationale:
The lateral side of the heel is the correct site for a heel stick to avoid injury to the bone.

A. Human papillomavirus. B. Rubella. C. Tetanus. D. Varicella.

Correct Answer is C

Explanation

Choice A rationale:
Human papillomavirus vaccine is not typically administered during pregnancy.
Choice B rationale:
Rubella vaccine is a live vaccine and is generally contraindicated during pregnancy.
Choice C rationale:
Tetanus vaccine is safe and recommended during pregnancy.
Choice D rationale:
Varicella is a live vaccine and is generally contraindicated during pregnancy.

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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

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Explanation

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Correct Answer is C

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