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 .
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While blood in the stool can be a sign of a problem in older children and adults, it is not uncommon for newborns to pass dark green or black stools (known as meconium) in the first few days after birth. This does not typically indicate a problem.
Choice B rationale
A newborn vomiting eight to ten times per day is a cause for concern. This could indicate a problem such as pyloric stenosis or gastroesophageal reflux disease, both of which require medical attention.
Choice C rationale
Cooling after each breastfeeding is not typically a sign of a problem. Newborns have immature temperature regulation systems, so slight variations in body temperature can occur.
Choice D rationale
Persistent crossing of the eyes in a newborn can be normal up to about 3 months of age. If it continues beyond this point, it may indicate a problem such as strabismus.
Correct Answer is A
Explanation
Choice A rationale
Facial asymmetry can occur as a result of a forceps-assisted birth. The pressure from the forceps can cause temporary changes in the shape of the baby’s face.
Choice B rationale
Caput succedaneum, a swelling of the scalp in a newborn, is not typically caused by forceps. It is more commonly associated with vacuum extraction.
Choice C rationale
Cephalohematoma, a bleeding underneath one of the cranial bones, is not typically caused by forceps. It is more commonly associated with vacuum extraction.
Choice D rationale
Subgaleal hemorrhage, bleeding into the space between the skull periosteum and the scalp galea aponeurosis, is not typically caused by forceps. It is more commonly associated with vacuum extraction.
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