A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take?

Administer a 500 mL bolus of 5% dextrose in water prior to the epidural administration.

Inform the client that the anesthetic effect will last for approximately 6 hours.

Obtain a 30 min electronic fetal monitoring (EFM) strip and prepare to give a bolus of Lactated Ringers solution prior to the epidural administration.

Have the client stand very still at the bedside with her arms at her side.

Answer and Explanation

The Correct Answer is C

A: Administering a 500 mL bolus of 5% dextrose in water is not necessary before the epidural administration, and it may not be recommended in active labor as it can increase the risk of fluid overload.

B: The duration of the anesthetic effect of the epidural can vary depending on the medication used, and it is not the nurse's priority during the preparation process.

C: Prior to administering epidural analgesia, the nurse should obtain a 30minute electronic fetal monitoring (EFM) strip to assess the fetal heart rate and monitor for any signs of fetal distress during the procedure.

D: Having the client stand very still with her arms at her side is not practical or necessary for epidural administration and could be uncomfortable for the client during labor.

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Correct Answer is D

Explanation

A) Retained bile in the liver results in delayed digestion: This statement is not related to the cause of heartburn.
B) Increased estrogen production causes increased secretion of hydrochloric acid: While hormonal changes during pregnancy can contribute to heartburn, it is specifically increased progesterone that leads to relaxation of the cardiac sphincter and delayed gastric emptying, which are more directly linked to heartburn.
C) Pressure from the growing uterus displaces the stomach: Uterine pressure on the stomach can lead to a feeling of fullness, but it is not the primary cause of heartburn during pregnancy.
D) Increased progesterone production causes relaxation of the smooth muscle relaxation of the cardiac sphincter and delayed gastric emptying: This is the correct answer. Increased progesterone levels during pregnancy relax the lower esophageal sphincter, leading to gastric acid reflux into the esophagus and causing heartburn.

A. Immediately report the situation to the client's provider and prepare the client for induction of labor. B. Encourage the client to walk around without the monitoring unit for 10 min, then resume monitoring. C. Turn the client onto her left side. D. Offer the client a snack of orange juice and crackers

Correct Answer is D

Explanation

A. Immediately report the situation to the client's provider and prepare the client for induction of labor.This option is premature. The absence of fetal movement for 15 minutes during a nonstress test does not immediately indicate a need for induction of labor. Other less invasive interventions should be attempted first to stimulate fetal movement.

B. Encourage the client to walk around without the monitoring unit for 10 min, then resume monitoring. While movement can sometimes stimulate fetal activity, removing the monitoring unit is not advisable during a nonstress test. Continuous monitoring is essential to accurately assess the fetal heart rate and movement.

C. Turn the client onto her left side.This position can improve uteroplacental blood flow and may help stimulate fetal movement. However, it is not the most effective initial intervention compared to offering a snack, which can provide a quicker response.

D. Offer the client a snack of orange juice and crackers.This is the correct intervention. The sugar in the orange juice can provide a quick source of energy to the fetus, potentially stimulating movement. Additionally, the act of eating can sometimes prompt fetal activity.

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A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a prenatal clinic is caring for a client who is at 12 weeks gestation. The client asks about the cause of her heartburn. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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