The nurse is caring for a laboring client who is requesting an epidural.
As the nurse prepares to start an IV, the client asks why it is necessary.
What would be the nurse’s best response?
“You won’t be able to eat, and this provides nutrition to you and the baby during childbirth.”
“Don’t worry about the IV, I have placed many IVs before.”
“The IV is in place to give the medication for relaxation before the epidural is placed.”
“The IV bolus will help to minimize the side effects of the epidural.”
The Correct Answer is C
Choice A rationale:
It is true that a laboring client may not be able to eat, but this is not the primary reason for starting an IV. The client can receive fluids and electrolytes through the IV to maintain hydration and energy levels.
However, this response does not directly address the client's question about why the IV is necessary for the epidural.
It's important to provide a clear and accurate explanation to help the client understand the purpose of the intervention.
Choice B rationale:
This response is dismissive of the client's concerns and does not provide any information about why the IV is necessary.
It's important to acknowledge the client's concerns and provide them with the information they need to make informed decisions about their care.
Choice C rationale:
This is the correct response. The IV is necessary to administer medication for relaxation before the epidural is placed.
The epidural is a regional anesthetic that blocks pain signals from the lower body.
The medication for relaxation helps to reduce anxiety and discomfort, which can make it easier to place the epidural.
It also helps to prevent the client from moving during the procedure, which could lead to complications.
Choice D rationale:
This response is not accurate. An IV bolus is not typically given to minimize the side effects of the epidural.
Side effects of the epidural, such as hypotension and nausea, are usually managed with other medications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice c. Negative.
Choice A rationale:
“Satisfactory” is not a standard term used to describe the results of a contraction stress test (CST). The terms typically used are “negative,” “positive,” “equivocal,” or “unsatisfactory.”
Choice B rationale:
“Unsatisfactory” is used when the test cannot be interpreted due to inadequate contractions or other technical issues. In this case, the client is experiencing contractions every three minutes, and the fetal heart rate (FHR) is being monitored effectively.
Choice C rationale:
A “Negative” CST indicates that there are no late decelerations of the FHR during contractions, suggesting that the fetus is not experiencing significant distress and is likely tolerating the contractions well.
Choice D rationale:
A “Positive” CST would indicate the presence of late decelerations of the FHR with at least 50% of contractions, suggesting fetal hypoxia and compromised placental function. Since there are no decelerations in this scenario, this choice is incorrect.
Correct Answer is B
Explanation
Choice A rationale:
Urine output (UO) does not completely stop during the oliguric phase of acute renal failure. While it is significantly reduced, some urine production still occurs. Complete cessation of urine output is known as anuria, which is a more severe condition and a medical emergency.
Anuria may occur in the most severe cases of acute renal failure, but it is not the defining characteristic of the oliguric phase.
It's crucial to distinguish between oliguria and anuria, as their management approaches differ significantly.
Choice B rationale:
During the oliguric phase of acute renal failure, urine output (UO) is less than 400 mL/24 hours. This is the defining characteristic of this phase.
The decrease in urine output is due to damage to the kidneys' filtering units, known as nephrons. As a result, the kidneys are unable to filter waste products and excess fluids effectively from the blood, leading to their accumulation in the body.
This reduced urine output can lead to various complications, including fluid overload, electrolyte imbalances, and a buildup of waste products in the blood (uremia).
Choice C rationale:
Urine output (UO) is always measured during the oliguric phase of acute renal failure. It is a vital clinical indicator to monitor the severity of kidney dysfunction and guide treatment decisions.
Accurate measurement of urine output is essential for assessing fluid balance, kidney function, and the effectiveness of treatment interventions.
Choice D rationale:
Urine output (UO) is not greater than 500 mL/24 hours during the oliguric phase of acute renal failure. A urine output greater than 500 mL/24 hours would indicate a non-oliguric phase of acute renal failure or a potential recovery phase.
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