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Patient Data

Exhibits

Review H and P, nurse's notes, laboratory results, flow sheet, and prescriptions. Click to highlight the findings that would indicate the client is progressing and ready for an epidural.

0245

Peripheral IV (PIV) started in left hand with 20 gauge catheter. Lab specimens 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. Instructed her and husband on slow breathing and relaxation techniques. Husband will assist wife breathing. Client instructed she can have IV pain medication if she needs it until time for epidural.

0330

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.

Peripheral IV (PIV) started in left hand with 20 gauge catheter

Lab specimens 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

Instructed her and husband on slow breathing and relaxation techniques

Performed artificial rupture of membranes with clear amniotic fluid

Client instructed she can have IV pain medication if she needs it until time for epidural

SVE reveals 5 cm dilated, 90% effaced and 0 station

Contractions are now every 3 to 4 minutes apart

Asking for epidural

SVE reveals 5 cm dilated, 90% effaced and 0 station.

Answer and Explanation

The Correct Answer is ["G","I","J","K","L"]

Contractions every 3 to 4 minutes, lasting 45 seconds: This frequency and duration of contractions suggest the client is in active labor, and the pain is becoming more intense, indicating readiness for pain management through epidural anesthesia.

Client's request for pain relief: The client’s request for an epidural due to increased pain is also a practical consideration for proceeding with epidural anesthesia. Her request aligns with the physical signs of progressing labor.

5 cm dilated, 90% effaced, 0 station: The client is in active labor with significant cervical change, meeting the typical criteria for an epidural, which is usually considered when the cervix is dilated to 4-5 cm.

Artificial rupture of membranes with clear amniotic fluid: This procedure typically accelerates labor and further confirms the client is in the active stage of labor, reinforcing the need for pain management at this point.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Determine how the client is administering the medication: While the nurse should assess medication administration, jaw pain could be a sign of a serious side effect, and reporting to the healthcare provider is the priority.
B. Advise the client to gargle with warm salt water twice daily: Gargling with salt water may provide some comfort but is not an appropriate solution for jaw pain related to bisphosphonate therapy.
C. Report the client's jaw pain to the healthcare provider: Jaw pain could be a sign of osteonecrosis of the jaw, a rare but serious side effect of bisphosphonates. Immediate reporting is essential.
D. Confirm that this is a common symptom of osteoporosis: Jaw pain is not a common symptom of osteoporosis and should be assessed further.

A. Brain damage with CP is not progressive but does have a variable course. B. CP is one of the most common permanent physical disability in children. C. Continued development of the brain lesion determines the child's outcome D. Severe motor dysfunction determines the extent of successful habilitation.

Correct Answer is A

Explanation

A. Cerebral palsy is caused by brain injury or abnormal development, but the damage itself does not worsen over time. The severity of symptoms can vary as the child grows, but it is not progressive.

B. While CP is a permanent disability, this response does not address the client’s concern about the progression of symptoms.

C. The brain lesion in CP does not continue to develop in most cases, so this explanation would not provide accurate information.

D. Severe motor dysfunction does not solely determine the child’s outcome, as therapy and early interventions can significantly improve functional abilities.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A female client is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

Correct Answer is C

Explanation

The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

Correct Answer is A

Explanation

The nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

Exhibits The client has started to wake up more, opening her eyes without stimulation and looking around the room. Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.

While caring for a toddler receiving oxygen via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement?

The client who has emphysema and recently experienced a stroke receives a prescription for a metered-dose inhaler with a spacer device. The client asks the nurse if using the spacer is necessary. Which information should the nurse provide?

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?

Exhibits Click to indicate which client goal is being met by each of the client data. Each column must have at least one response selected.