A peripheral IV (PIV) is started in the left hand with a 20-gauge catheter.
Lab specimens are drawn.
IV fluids of lactated Ringer's started infusing at 75 mL/hour.
Contractions are now every 4 minutes, lasting 45 seconds.
Mother says they are getting more painful.
She and her husband are instructed on slow breathing and relaxation techniques.
Husband will assist with her breathing.
Client is instructed she can have pain medication if she needs it until time for epidural.
Contractions are now every 3 to 4 minutes apart and client reports they are really hurting, asking for epidural.Healthcare provider (HCP) to bedside. SVE reveals 5 cm dilated, 90% effaced and 0 station.Performed artificial rupture of membranes with clear amniotic fluid.
Client is prepped for immediate cesarean section due to fetal distress.
Client is instructed to start pushing as the baby is crowning.
Epidural is administered, and client experiences immediate pain relief.
The Correct Answer is A
Choice A rationale
The scenario indicates that the client's contractions are increasing in frequency and intensity, and she reports significant pain, prompting a request for an epidural. The cervical exam shows she is 5 cm dilated and 90% effaced, with the baby at 0 station, which is typical for the active phase of labor. This is the appropriate time for an epidural, as pain management is often needed when contractions become more intense and dilation progresses. Clear amniotic fluid after artificial rupture of membranes also suggests no immediate complications.
Choice B rationale
Immediate cesarean section is generally reserved for situations of fetal distress or other obstetric emergencies. There is no mention of fetal heart rate abnormalities or other signs of distress in the scenario. While MS can complicate pregnancy, it does not automatically necessitate a cesarean section without specific indications. The decision for cesarean should be based on maternal or fetal indications not present in this case.
Choice C rationale
The instruction to start pushing is only appropriate during the second stage of labor when the cervix is fully dilated (10 cm). The client is 5 cm dilated, indicating she is still in the active phase of the first stage of labor. Encouraging pushing at this stage would be premature and could cause unnecessary exhaustion and potential harm to the cervix and fetus. Pushing is typically reserved for the final stage when the baby's head is crowning.
Choice D rationale
Administering an epidural and experiencing immediate pain relief aligns with the standard protocol for labor analgesia when requested by the client. Epidural anesthesia is a common and effective method for pain management during labor. This option respects the client's expressed need for pain relief and involves the healthcare provider in safely administering the epidural. Immediate relief from pain can help the client focus on labor progression and reduce stress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Crushing zolpidem to increase absorption is inappropriate because it is a controlled-release medication. Crushing the tablet would disrupt the controlled-release mechanism, leading to rapid absorption, increased side effects, and potentially dangerous consequences.
Choice B rationale
Taking zolpidem before bedtime is correct because it is a medication prescribed for insomnia. It helps the patient fall asleep more quickly by acting on the central nervous system to induce sleep, and it should be taken when the patient is ready to sleep.
Choice C rationale
Administering zolpidem with a meal is not recommended. Food can delay the absorption of the medication, reducing its effectiveness in helping the patient fall asleep promptly.
Choice D rationale
Storing zolpidem at room temperature is correct, but it is not a critical point of patient education. The emphasis should be on taking the medication as prescribed and understanding its purpose and potential side effects.
Correct Answer is B
Explanation
Choice A rationale
Explaining the ELISA test for confirmation is unnecessary as the client is already confirmed HIV positive. Repeating the test may cause confusion and anxiety without offering additional benefit at this stage.
Choice B rationale
Identifying support systems in the client's life is crucial for addressing the emotional and psychological impact of being HIV positive and a victim of rape. Support systems, such as family, friends, or support groups, can provide the necessary emotional support and practical assistance to help the client cope with the challenges.
Choice C rationale
Inquiring about plans to further education may not be timely or appropriate in the context of the client's current emotional state. The priority should be addressing the client's immediate mental health needs and ensuring they have adequate support systems in place.
Choice D rationale
Exploring feelings of hope for the future is important but may not be the immediate priority. The client is currently experiencing significant emotional distress, so addressing their immediate mental health needs and ensuring support is a higher priority.
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