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
An older client one day postoperative with a colostomy for colon cancer may have complex needs that require the expertise of an RN rather than a PN.
Choice B rationale
An older adult scheduled for foot amputation due to diabetes complications may also have complex needs and potential complications that necessitate the supervision of an RN.
Choice C rationale
An adult with alcoholism, cirrhosis, and hepatic encephalopathy is likely to have complex medical issues and require close monitoring and interventions, best suited for an RN.
Choice D rationale
An adult one day postoperative for a laparoscopic cholecystectomy is generally stable and has less complex needs, making them an appropriate assignment for a PN.
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale
Raspberries are an excellent source of dietary fiber, with approximately 8 grams of fiber per cup. They are rich in both soluble and insoluble fibers, which help promote healthy digestion and bowel regularity. The high fiber content in raspberries can help prevent and alleviate constipation, which is particularly beneficial for individuals with hemorrhoids.
Choice B rationale
Oatmeal is another high-fiber food, providing about 4 grams of fiber per cup. It contains a type of soluble fiber called beta-glucan, which forms a gel-like substance in the intestines, helping to soften stool and improve bowel movements. Including oatmeal in the diet can help reduce the discomfort associated with hemorrhoids.
Choice C rationale
Scrambled eggs are a good source of protein but are low in dietary fiber. They do not contribute to increasing the fiber intake needed to alleviate hemorrhoid symptoms. Although they can be part of a balanced diet, they are not specifically beneficial for a high-fiber diet.
Choice D rationale
Bacon slices are high in fat and low in fiber. Consuming high-fat foods can lead to constipation, which can worsen hemorrhoid symptoms. Bacon does not provide the necessary fiber to promote healthy digestion and bowel movements.
Choice E rationale
Raisin bran muffins are a high-fiber food option, with both the bran and raisins contributing to their fiber content. Bran is rich in insoluble fiber, which adds bulk to the stool and helps prevent constipation. Raisins also contain fiber, making raisin bran muffins a suitable choice for individuals with hemorrhoids.
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