A nurse is caring for a client who is in active labor and requesting an epidural. Which of the following actions should the nurse take?

Give ondansetron IV to the client.

Administer IV fluid bolus to the client.

Delay the epidural until the client is dilated to 7 cm.

Initiate oxygen via nonrebreather to support patterned breathing

Answer and Explanation

The Correct Answer is B

A. Ondansetron is used to treat nausea but is not a routine pre-epidural intervention.
B. Administering an IV fluid bolus before epidural anesthesia helps prevent hypotension caused by sympathetic blockade.
C. Epidurals can be administered earlier than 7 cm dilation based on maternal request and clinical assessment.
D. Oxygen administration is not routinely required before an epidural unless fetal distress or maternal hypoxia is present.

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Correct Answer is C

Explanation

A. Hypotension, not hypertension, is expected in hemorrhagic shock due to blood loss.
B. Tachypnea, not bradypnea, usually occurs as the body tries to compensate for hypoxia.
C. Tachycardia is an early compensatory response to blood loss to maintain cardiac output.
D. Oliguria (decreased urine output), not polyuria, is expected due to poor perfusion of kidneys in shock.

A. Lay the tape measure horizontally over the middle of the client's abdomen. B. Place the client in a left-lateral position to obtain the measurement. C. Measure from the upper border of the symphysis pubis to the upper border of the fundus D. Ensure that the client has a full bladder before taking the measurement.

Correct Answer is C

Explanation

A. The tape measure should be placed vertically, not horizontally, over the abdomen to measure fundal height accurately.
B. The client should be in a supine position, not left-lateral, during the measurement.
C. Fundal height is measured from the upper border of the symphysis pubis to the upper border of the uterine fundus.
D. A full bladder can distort the measurement, so the client should have an empty bladder before measuring fundal height.

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A nurse is caring for a client who is in active labor and requesting an epidural. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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