Exhibits

Click to indicate which interventions the nurse would include in the plan of care to support the expected outcomes of adequate epidural anesthesia on the mother and the fetus.

Each column must have a least one but may have more than response option selected

Side positioning

Urinary drainage

Assisting with pushing efforts

Administering IV fluids

Monitoring blood pressure

Answer and Explanation

The Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A,B"},"E":{"answers":"A,B"}}

Side positioning can help with pain relief and prevent hypotension, which is beneficial for both maternal and fetal well-being. Urinary drainage (B) is typically a maternal intervention to manage the effects of epidural anesthesia on bladder function. Assisting with pushing efforts is a maternal intervention that supports the mother during the second stage of labor. Administering IV fluids is an intervention for the mother to maintain hydration and blood pressure, which indirectly benefits the fetus. Monitoring blood pressure is essential for both maternal and fetal health, as stable maternal blood pressure is critical for adequate fetal perfusion.

Nursing Test Bank

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Correct Answer is B

Explanation

A. Sluggish blood return suggests a need for assessment but is not immediately critical.

B. A red streak tracking the vein indicates phlebitis or infection, requiring immediate intervention to prevent complications such as thrombophlebitis or sepsis.
C. Circumferential skin irritation is concerning but not as urgent as a sign of infection.
D. A cool sensation might indicate infiltration but is less critical compared to signs of infection or phlebitis.

A. Initiate toileting schedule. B. Monitor for signs of anemia. C. Encourage intake of high potassium foods. D. Provide perineal skin barrier cream.

Correct Answer is B

Explanation

A. A toileting schedule is unnecessary for an anuric client as they do not produce urine.
B. Anemia is a common complication of chronic kidney disease due to reduced erythropoietin production, so monitoring for signs of anemia is important.
C. High potassium foods should be avoided as impaired kidney function can lead to hyperkalemia.
D. While perineal skin care is important, it is not as critical as monitoring for anemia in this context.

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Exhibits Click to indicate which interventions the nurse would include in the plan of care to support the expected outcomes of adequate epidural anesthesia on the mother and the fetus. Each column must have a least one but may have more than response option selected

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing a routine assessment of an IV site for a client receiving both IV fluids and medications through the line. The client reports tenderness when the nurse touches the arm above the site. Which finding should the nurse expect which will require immediate intervention?

Correct Answer is B

Explanation

The nurse is planning care for a client with chronic kidney disease who is a resident at a long-term nursing facility. The client is anuric and has hemodialysis 3 times a week. Which intervention should the nurse include in the client's plan of care?

Correct Answer is B

Explanation

Patient Data Exhibits The healthcare provider has obtained the arterial blood gas and chest X-ray results. New prescriptions have been entered in the client's electronic health record. Nursing Action: Indicated/ Contraindicated

Patient's data Exhibits The nurse obtains verbal handoff from the outpatient clinic nurse, reviews the electronic health record, and completes an initial assessment including vital signs. Which assessment findings require follow up by the nurse? Select all that apply.

The charge nurse observes a new nurse preparing to irrigate an intravenous catheter. The new nurse is attaching an 18-gauge needle. Which action should the charge nurse take?

Which instruction should the nurse delegate to an unlicensed assistive personnel (UAP)?

After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to the practical nurse (PN)?

A client with unilateral hearing loss is admitted for a scheduled surgery. Which technique should the nurse use to provide education about pain relief options?

Exhibits

Click to indicate which interventions the nurse would include in the plan of care to support the expected outcomes of adequate epidural anesthesia on the mother and the fetus.

Each column must have a least one but may have more than response option selected