A nurse is caring for a 26-year-old female client who is in active labor in the labor and delivery unit.
The client has requested epidural anesthesia, and it has been administered to manage her pain during labor. The nurse is now monitoring her condition closely.
Fetal decelerations
Reports of pain
Nausea
Dizziness
Hypotension
Difficulty breathing
Correct Answer : A,E,F
Choice A rationale: Fetal decelerations require immediate action because they indicate potential fetal distress. Continuous fetal monitoring is essential to assess the fetus's well-being, and any signs of distress must be addressed promptly to ensure a safe delivery.
Choice E rationale: Hypotension is a common side effect of epidural anesthesia and can lead to decreased blood flow to the fetus. Immediate intervention, such as administering IV fluids or medications, is necessary to stabilize the mother's blood pressure and ensure adequate fetal perfusion.
Choice F rationale: Difficulty breathing is a critical sign that may indicate a severe reaction to the epidural anesthesia or other complications. Immediate assessment and intervention are required to ensure the mother's respiratory status is stable and to address any underlying issues.
Choice B rationale: Reports of pain, while important, do not require immediate emergency action compared to the other findings. Pain management should be adjusted accordingly, but it does not pose an immediate threat to the mother or fetus.
Choice C rationale: Nausea, while uncomfortable, is a common side effect of epidural anesthesia and does not require immediate emergency intervention. It can be managed with antiemetic medications.
Choice D rationale: Dizziness can be a side effect of epidural anesthesia or hypotension, but it is not as critical as the other findings that require immediate emergency attention. It should be monitored and addressed as part of overall care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: While psychological assessment is important, it is not the primary focus for assessing outcomes in this case. The client's physical health conditions and the impact on her daily living and functional ability are more directly relevant.
Choice B rationale: Financial security is not the primary concern in this context. The primary focus is on the client's health and ability to perform activities of daily living (ADLs), which is addressed by evaluating functional improvement.
Choice C rationale: Quality of life is a broad concept that includes many aspects such as emotional, social, and physical well-being. While it is relevant, the primary outcome measure in this context is the client's functional improvement related to her health conditions and ability to manage ADLs.
Choice D rationale: Functional improvement is the correct focus for evaluating the client's outcomes. This includes her ability to perform activities of daily living (ADLs) and manage her health conditions. The nurse should assess how well the client can maintain or improve her functional abilities with the additional care provided.
Correct Answer is ["1000"]
Explanation
Step 1 is 500 mL ÷ 30 min.
Step 2 is 16.67 mL/min × 60 min/hour. Answer: 1000 mL/hour.
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