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 A
Explanation
Choice A rationale
A client with a positive Mantoux test and sputum cultures positive for acid-fast bacillus (AFB) requires a negative airflow room and airborne precautions. This is to prevent the spread of tuberculosis (TB), an infectious disease that can be transmitted through airborne particles. The use of a particulate respirator mask by healthcare personnel is essential in protecting themselves from inhaling infectious aerosols. Implementing these precautions is critical in controlling the spread of TB within healthcare settings and ensuring patient and staff safety.
Choice B rationale
A client with genital herpes simplex II lesions does not require a negative airflow room or airborne precautions. Herpes simplex virus (HSV) is primarily transmitted through direct contact with infected lesions or body fluids. Standard precautions, including contact precautions when dealing with lesions, are adequate to prevent the spread of HSV. Negative airflow rooms and airborne precautions are not necessary for managing this condition.
Choice C rationale
Scarlet fever, complicated with pneumonia, primarily requires standard and droplet precautions rather than airborne precautions. Scarlet fever is caused by group A Streptococcus, which is spread through respiratory droplets. While pneumonia can increase the severity of the infection, negative airflow rooms and particulate respirators are not typically required. Droplet precautions, such as wearing masks and maintaining distance, are sufficient to prevent transmission.
Choice D rationale
Scabies is a parasitic infestation that spreads through direct skin-to-skin contact or contact with contaminated items such as bedding and clothing. Negative airflow rooms and airborne precautions are not necessary for managing scabies. Standard and contact precautions, including wearing gloves and gowns and thoroughly cleaning and disinfecting contaminated items, are adequate to prevent the spread of the mites causing scabies. The use of a particulate respirator mask is not required.
Correct Answer is C
Explanation
Choice A rationale
Consulting with a nurse who shares the same religious beliefs may provide insight, but it may not fully address the client's unique care preferences and individual needs.
Choice B rationale
Researching the religion on social media platforms can offer information, but it is not a substitute for understanding the client's specific preferences and requirements.
Choice C rationale
Asking the client about individual care preferences is the best approach, ensuring that care is personalized and respectful of the client's religious beliefs, leading to better compliance and satisfaction.
Choice D rationale
Explaining that every client receives the same high level of care is important but does not address the client's specific religious concerns and preferences.
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