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.

Decrease the IV flow rate.

Monitor fetal heart rate

Administer ampicillin IV

Place client in left lateral position.

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.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is []

Explanation

Potential Condition: Opioid intoxication

Actions to Take:

Obtain a prescription for naloxone
Prepare to initiate mechanical ventilation

Parameters to Monitor:

Pupillary reaction,
Respiratory rate

Rationale:

Potential Condition: The client presents with shallow breathing, slurred speech, confusion, pupillary constriction, and bradycardia, which are classic signs of opioid intoxication. The history of back pain also suggests possible opioid use.
Actions to Take:
- Naloxone is an opioid antagonist that can rapidly reverse respiratory depression caused by opioid overdose.
- Mechanical ventilation may be necessary if respiratory depression is severe and does not improve with naloxone administration.
Parameters to Monitor:
- Pupillary reaction is important because opioids cause pupillary constriction (miosis). Improvement in pupillary size and reaction indicates the opioid effects are wearing off.
- Respiratory rate should be closely monitored since opioid overdose primarily affects respiratory drive, leading to hypoxia and potential respiratory failure.

A. Obtain a tympanogram reading prior to initiating the test. B. Place a vibrating tuning fork on the top of the child's head. C. Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears. D. Measure the amount of time the child can hear the sound.

Correct Answer is B

Explanation

A. Obtain a tympanogram reading prior to initiating the test. This is incorrect because a tympanogram assesses middle ear function and is not part of the Weber test, which evaluates hearing loss type.
B. Place a vibrating tuning fork on the top of the child's head. This is correct because the Weber test involves placing a vibrating tuning fork on the midline of the skull to determine if sound is heard equally in both ears, helping to differentiate between conductive and sensorineural hearing loss.
C. Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears. This is incorrect because this describes the Rinne test, which compares air conduction to bone conduction.
D. Measure the amount of time the child can hear the sound. This is incorrect because the Weber test does not measure duration but assesses lateralization of sound perception.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

A school nurse is using the Weber's test to check a child's hearing acuity. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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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 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.