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

Choice A rationale
Airborne precautions are used for diseases that are spread through tiny droplets in the air, such as tuberculosis or chickenpox. Clostridium difficile is not spread in this manner.
Choice B rationale

Droplet precautions are used for diseases that are spread through larger droplets, such as influenza or pertussis. Clostridium difficile is not spread in this manner.
Choice C rationale
This is the correct answer. Contact precautions are used for diseases that are spread through direct contact with the patient or their environment. Clostridium difficile is a bacterium that can be present in feces and can contaminate surfaces, so contact precautions are appropriate.
Choice D rationale
Protective environment precautions are used for patients who have a compromised immune system, such as those undergoing stem cell transplants. These precautions are not typically used for patients with Clostridium difficile.

A. Apply hydrating lotion to the newborn’s skin prior to treatment. B. Provide the newborn with 15 mL glucose water after each feeding. C. Turn the newborn every 4 hours. D. Close the newborn’s eyes before applying eyepatches.

Correct Answer is D

Explanation

Choice A rationale

Applying hydrating lotion to the newborn’s skin prior to treatment is not recommended. The goal of phototherapy is to expose the newborn’s skin to light, and applying lotion could potentially interfere with the effectiveness of the treatment.
Choice B rationale
Providing the newborn with 15 mL glucose water after each feeding is not a standard part of phototherapy treatment. The newborn should continue to receive regular feedings, but additional glucose water is not typically necessary.
Choice C rationale
Turning the newborn every 4 hours is not sufficient during phototherapy. The newborn should be repositioned frequently, ideally every 2-3 hours, to expose all areas of the skin to the light.
Choice D rationale
It is important to protect the newborn’s eyes during phototherapy to prevent damage from the light. Therefore, the newborn’s eyes should be covered with special patches whenever the lights are on.

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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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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?