A patient was received one hour after delivering a 9 lb 1 oz (4.1 kg) female baby.
Her vital signs are as follows: Temperature 100.4° F (38° C) orally, Heart rate 86 beats/minute, Respiratory rate 16 breaths/minute, Blood pressure 102/12 mm Hg, Pain 4 on a 0 to 10 pain scale.
She was assisted to the bathroom where she voided 150 mL of clear yellow urine.
Lochia rubra is moderate with small clots, no foul odor noted.
The fundus is firm at the umbilicus.
The episiotomy edges are well approximated, with no redness, edema, drainage, or ecchymosis.
There is no pain, redness, or swelling in the calves.
A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing via an 18-gauge peripheral IV in the left forearm at 125 mL per hour, with 500 mL remaining in the bag.
The IV is patent, without redness or swelling, and can be discontinued when this bag’s infusion is complete.
The Correct Answer is ["-"]
Step 1: The patient’s vital signs are as follows: Temperature 100.4° F (38° C) orally, Heart rate 86 beats/minute, Respiratory rate 16 breaths/minute, Blood pressure 102/12 mm Hg, Pain 4 on a 0 to 10 pain scale.
Step 2: She was assisted to the bathroom where she voided 150 mL of clear yellow urine. Lochia rubra is moderate with small clots, no foul odor noted. The fundus is firm at the umbilicus. The episiotomy edges are well approximated, with no redness, edema, drainage, or ecchymosis. There is no pain, redness, or swelling in the calves.
Step 3: A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing via an 18-gauge peripheral IV in the left forearm at 125 mL per hour, with 500 mL remaining in the bag. The IV is patent, without redness or swelling, and can be discontinued when this bag’s infusion is complete.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While it’s good that the client has reduced her alcohol intake, consuming alcohol during pregnancy can cause problems for the baby throughout pregnancy, including before a woman knows she is pregnant. Therefore, praising the client for her actions and offering to discuss ways to decrease consumption even more might not be enough.
Choice B rationale
Insisting that the client stop all alcohol use and drawing a blood alcohol level at each prenatal visit could be seen as invasive and might not address the underlying issue of alcohol dependency.
Choice C rationale
Notifying child protective services of the client’s illicit drug use and probable child endangerment is not applicable in this situation as the client has not mentioned any illicit drug use.
Choice D rationale
Referring the client to an outpatient alcohol abuse program for disulfiram therapy could be the most beneficial action. Disulfiram is a drug that is used to support the treatment of chronic alcoholism by producing an acute sensitivity to alcohol.
Correct Answer is B
Explanation
The correct answer is choice A. Manual resuscitation bag and B. An advanced airway kit.
Choice A rationale:
A manual resuscitation bag is essential in pediatric emergencies to provide immediate ventilation support if the child experiences respiratory failure or arrest. This device allows healthcare providers to manually deliver breaths to the patient, ensuring adequate oxygenation and ventilation until more advanced airway management can be established.
Choice B rationale:
An advanced airway kit is crucial for managing a difficult airway, especially in pediatric patients who may have anatomical differences making intubation challenging. This kit typically includes tools for endotracheal intubation, laryngeal mask airways, and other devices to secure the airway and ensure the child can breathe effectively.
Choice C rationale:
A dose of subcutaneous epinephrine is primarily used for treating severe allergic reactions or anaphylaxis. While it is a critical medication in emergencies involving anaphylaxis, it is not directly related to the immediate need for airway management and ventilation in this scenario.
Choice D rationale:
The child’s favorite toy can be helpful in calming and distracting the child during medical procedures, reducing anxiety and making the experience less traumatic. However, it is not a medical necessity for the placement of an intravenous line or for managing respiratory distress.
Choice E rationale:
Nebulized albuterol is used to treat bronchospasm and wheezing, commonly seen in asthma or reactive airway disease. While it is an important medication for managing respiratory symptoms, it does not address the immediate need for airway management and ventilation support in a critical situation.
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