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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?

A.

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

B.

Report of relief of pruritus

C.

Increased urinary output

D.

Blood pressure 110/70 mm Hg .

Answer and Explanation

The Correct Answer is D

Choice A rationale
The report of perineal pain as 0 on a scale of 0 to 10 is not directly related to the effectiveness of the IV bolus of lactated Ringer’s. Perineal pain is more associated with the birthing process and not with the administration of IV fluids.
Choice B rationale
Relief of pruritus is not a direct indication of the effectiveness of the IV bolus of lactated Ringer’s. Pruritus, or itching, can be a side effect of certain medications or a symptom of various conditions, but it is not typically associated with the administration of IV fluids.
Choice C rationale
 

While increased urinary output can be a sign of adequate hydration, it is not the primary indicator of the effectiveness of a bolus of lactated Ringer’s. Urinary output can be influenced by various factors, including kidney function and fluid intake, but a single instance of increased urinary output does not necessarily indicate that the IV bolus was effective.
Choice D rationale
The primary goal of administering a bolus of IV fluids like lactated Ringer’s in a client who is in labor and has a prescription for spinal anesthesia is to maintain or improve the client’s hemodynamic status, which includes maintaining a stable blood pressure. Therefore, a blood pressure reading of 110/70 mm Hg indicates that the IV bolus was effective.

 


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Related Questions

Correct Answer is C

Explanation

Choice A rationale
Telling a grieving mother that not holding her baby will make letting go much harder can be seen as insensitive and may not be true for all individuals. Each person’s grief process is unique.
Choice B rationale
Assuring the mother that she will be able to have another baby when she’s ready may be seen as dismissive of her current loss. It’s important to acknowledge the pain of losing this specific child, rather than focusing on future children.
Choice C rationale
This is the correct answer. Offering the mother the opportunity to bathe and dress her baby can provide a sense of closure and a chance to say goodbye. It allows the mother to care for her baby in the short time they have together.
Choice D rationale
While some parents may find comfort in naming their baby, it should not be presented as something the mother “should” do. The decision to name the baby is a personal one and should be left up to the parents.

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"C"},"E":{"answers":"C"},"F":{"answers":"A"}}

Explanation


• Fundus 2 cm above umbilicus: This could be a sign of potential worsening condition as it might indicate uterine atony, a condition in which the uterus fails to contract after the delivery, leading to continuous bleeding.
• Blood pressure 90/60 mm Hg: This could be an indication of potential improvement as it is within the normal range, and lower than the previous reading which was elevated due to preeclampsia.
• Heart rate 110/min: This could be a sign of potential worsening condition as it is slightly elevated, which could be a response to blood loss.
• Continued heavy vaginal bleeding: This could be a sign of potential worsening condition as it might indicate postpartum hemorrhage.
• Client reports feeling dizzy: This could be a sign of potential worsening condition as it might be due to blood loss leading to decreased perfusion to the brain.
• Cloudy urine: This is unrelated to the diagnosis. It could be due to dehydration or a urinary tract infection, but it’s not directly related to preeclampsia or postpartum hemorrhage.

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