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

Report of relief of pruritus

Increased urinary output

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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Correct Answer is C

Explanation

Correct answer: C. Poor feeding

Newborns exposed to methadone in utero are at risk for neonatal abstinence syndrome (NAS), which can manifest with:

Poor feeding due to uncoordinated suck and swallow reflexes, irritability, and gastrointestinal symptoms.
High-pitched cry, not weak—so option B is incorrect.
Exaggerated Moro reflex, not absent—so option A is incorrect.
Tachypnea (rapid breathing), often >60/min—so a respiratory rate of 30/min is abnormally low and not expected in this context, making option D incorrect.

A. Perform a fundal massage. B. Assess for abdominal tenderness. C. Obtain serial hemoglobin and hematocrit. D. Monitor vital signs closely.

Correct Answer is C

Explanation

Choice A rationale
Performing a fundal massage is not the appropriate action for a client with placenta previa who is experiencing a large amount of vaginal bleeding. Fundal massage is typically used to stimulate contractions and reduce postpartum hemorrhage after the delivery of the placenta. However, in the case of placenta previa, where the placenta is covering the cervix, a fundal massage could potentially cause more harm and increase bleeding.
Choice B rationale
Assessing for abdominal tenderness is not the most immediate action for a nurse to take when a client with placenta previa is exhibiting a large amount of vaginal bleeding. While abdominal tenderness could indicate a complication such as placental abruption, the primary concern with placenta previa is the risk of severe bleeding that can endanger both the mother and the baby.
Choice C rationale
Obtaining serial hemoglobin and hematocrit is the correct action in this situation. These laboratory tests are important for monitoring the client’s blood loss and determining the need for a possible blood transfusion. With a large amount of vaginal bleeding, the client is at risk for anemia and hypovolemic shock, so close monitoring of blood levels is crucial.

Choice C rationale

Monitoring vital signs closely is an important part of care for any client, but it is not the most specific action a nurse should take for a client with placenta previa who is experiencing a large amount of vaginal bleeding. Vital sign changes could indicate worsening of the client’s condition, but these changes often occur late in the progression of blood loss. Therefore, while important, it is not the most immediate action to take.

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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 assessing a newborn of a client who reported methadone use during pregnancy. What manifestations should the nurse expect the newborn to exhibit?

Correct Answer is C

Explanation

A nurse is caring for a client who is at 32 weeks of gestation and has placenta previa. The client is exhibiting a large amount of vaginal bleeding.What 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?