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 D
Explanation
Choice A rationale: While psychological assessment is important, it is not the primary focus for assessing outcomes in this case. The client's physical health conditions and the impact on her daily living and functional ability are more directly relevant.
Choice B rationale: Financial security is not the primary concern in this context. The primary focus is on the client's health and ability to perform activities of daily living (ADLs), which is addressed by evaluating functional improvement.
Choice C rationale: Quality of life is a broad concept that includes many aspects such as emotional, social, and physical well-being. While it is relevant, the primary outcome measure in this context is the client's functional improvement related to her health conditions and ability to manage ADLs.
Choice D rationale: Functional improvement is the correct focus for evaluating the client's outcomes. This includes her ability to perform activities of daily living (ADLs) and manage her health conditions. The nurse should assess how well the client can maintain or improve her functional abilities with the additional care provided.
Correct Answer is C
Explanation
Choice A rationale
Measuring and discarding residual gastric contents before feeding is generally avoided in infants because it can disrupt gastrointestinal function and increase the risk of aspiration. Instead, monitoring for signs of intolerance or high residuals through clinical observation is preferred.
Choice B rationale
Using the syringe plunger to push formula at a rate of 5 mL per minute is inappropriate because it can create excessive pressure, leading to discomfort, aspiration, or injury to the gastrointestinal tract. Gravity feeding or using an appropriate pump at a controlled rate is safer.
Choice C rationale
Holding the infant with head and shoulders slightly elevated during feeding is recommended. This position helps to prevent aspiration by ensuring that the formula flows smoothly through the esophagus and into the stomach, reducing the risk of regurgitation.
Choice D rationale
Microwaving refrigerated formula to room temperature is unsafe because microwaving can create hot spots in the formula, posing a burn risk to the infant. It is safer to warm the formula by placing the bottle in warm water and ensuring an even temperature.
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