The healthcare provider (HCP) prescribes 0.99% normal saline 500 mL IV bolus to be infused over 30 minutes. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only) .

Choice A rationale

Assisting the client to void before walking can prevent potential incontinence episodes, which might be embarrassing for the client. Additionally, a full bladder can increase the risk of falls due to discomfort or urgency to get to the restroom quickly.

Choice B rationale

While instructing the client about signs of orthostatic hypotension is important, it is not within the scope of practice for an unlicensed assistive personnel (UAP) to provide such instructions. This task falls under the responsibility of a licensed nurse.

Choice C rationale

Measuring the client's vital signs before walking helps to assess the client's baseline status and ensures that the client is stable enough to engage in physical activity. Any abnormal readings could indicate the need to postpone or modify the activity.

Choice D rationale

Reporting the onset of any dizziness or light-headedness is crucial for ensuring the client's safety during activity. These symptoms could indicate underlying issues such as orthostatic hypotension or other cardiovascular problems that need to be addressed promptly.

Choice E rationale

Determining if a gait belt is needed ensures that the client receives appropriate support while walking. A gait belt can provide additional stability and help prevent falls, especially for clients with limited tolerance for activity.

Rationale for correct answer:

• Pain relief: The purpose of epidural anesthesia is to provide pain relief during labor. Since the nurse’s notes state that the client is comfortable and reports adequate pain relief, it demonstrates that the epidural anesthesia is effective.
• Fetal heart rate: Monitoring fetal heart rate is crucial to ensure the well-being of the baby during labor. The nurse’s notes state that the fetal heart rate is within normal limits, indicating that the epidural anesthesia has not adversely affected the baby and is working effectively.

Rationale for incorrect answers:

• Good urine output: While good urine output is important, it is not a direct indicator of the effectiveness of epidural anesthesia. It does not provide information about pain relief or fetal well-being.
• Vital signs: Vital signs are important to monitor but do not specifically indicate the effectiveness of epidural anesthesia in terms of pain relief and fetal well-being.
• Progression of labor: The progression of labor is influenced by various factors, not just the effectiveness of epidural anesthesia. It is not a direct measure of the epidural’s effectiveness.
• Labor augmentation: Labor augmentation refers to interventions to stimulate labor. It is not related to the effectiveness of epidural anesthesia.