How it Works
Try Naxlex NCLEX-RN (Free-Trial)

A nurse is caring for a client who is in active labor.

Exhibits

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.

A.

Decrease the IV flow rate.

B.

Monitor fetal heart rate

C.

Administer ampicillin IV

D.

Place client in left lateral position.

E.

Request a prescription for ephedrine.

Answer and Explanation

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.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is ["A","B","C","D","E"]

Explanation

  • Heart rate decreased from 104/min to 88/min, indicating improved hemodynamic stability.
  • Respiratory rate decreased from 20/min to 16/min, suggesting relaxation and reduced distress.
  • Blood pressure slightly decreased from 132/84 mm Hg to 122/80 mm Hg, indicating improved comfort and reduced pain-related stress response.
  • Pain level decreased to 3/10 after epidural placement, demonstrating effective pain management.
  • FHR 150/min with moderate variability and accelerations present, no decelerations, indicating fetal well-being.

Correct Answer is B

Explanation

A. Choose the client's dominant arm for IV access whenever possible. The nondominant arm is preferred to minimize interference with daily activities.
B. Select a site proximal to previous venipuncture sites. This is the appropriate action because using a site above a previous one ensures better vein integrity and reduces complications.
C. Initiate IV access on the palmar side of the client's wrist. This site should be avoided as it is more painful and increases the risk of nerve damage.
D. Insert a larger gauge IV catheter to prevent phlebitis. A smaller gauge catheter is preferred when possible, as larger catheters can increase the risk of vein irritation and phlebitis.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register