A nurse is caring for a client who is in active labor.
The nurse is caring for a client following the insertion of an epidural. For each nursing intervention, click to specify if the intervention is essential or contraindicated for the client.
Decrease the IV flow rate.
Monitor fetal heart rate
Administer ampicillin IV
Place client in left lateral position.
Request a prescription for ephedrine.
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}
Essential Interventions:
- Monitor fetal heart rate
- Administer ampicillin IV
- Place client in left lateral position
- Request a prescription for ephedrine
Contraindicated Intervention:
- Decrease the IV flow rate
Rationale:
- Monitor fetal heart rate (Essential): Epidural anesthesia can cause maternal hypotension, leading to decreased uteroplacental perfusion. Continuous fetal heart rate monitoring ensures the fetus is tolerating labor well.
- Administer ampicillin IV (Essential): The client tested positive for Group B Streptococcus (GBS) at 37 weeks, requiring prophylactic IV antibiotic administration during labor to prevent neonatal infection.
- Place client in left lateral position (Essential): This position improves venous return, enhances placental perfusion, and prevents hypotension caused by epidural anesthesia.
- Request a prescription for ephedrine (Essential): Epidural anesthesia can cause maternal hypotension, and ephedrine is a vasopressor that can help restore blood pressure if needed.
- Decrease the IV flow rate (Contraindicated): IV fluids should be maintained or increased to prevent hypotension, a common side effect of epidural anesthesia. Reducing the IV rate could exacerbate hypotension and fetal distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["10"]
Explanation
ML
The formula to calculate the IV flow rate is:
mL/hr =
(Desireddose(units/hr)×Totalvolume(mL))/ Available dose
Substituting the given values:
(1,000×250)/25000
= 250,000/25,000
= 10ml/hr
Correct Answer is A
Explanation
A. A child with cystic fibrosis and difficulty clearing secretions is the priority because airway clearance is critical in cystic fibrosis. Mucus buildup can lead to respiratory distress and infection, requiring immediate intervention.
B. A child with an atrial septal defect and a heart rate of 120/min is not the priority because a heart rate of 120/min is within the expected range for a 3-year-old and does not indicate immediate distress.
C. A child with type 1 diabetes and a blood sugar of 150 mg/dL is not the priority because this blood glucose level is slightly elevated but not critical.
D. A child with diarrhea and abdominal pain requires assessment, but dehydration or electrolyte imbalance develops over time. Airway issues take priority over gastrointestinal symptoms.
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