a client is in active labor and is receiving an epidural for pain relief which of the following should the nurse monitor as the priority
Logo

Nursing Elites

ATI LPN

PN ATI Capstone Maternal Newborn

1. A client is in active labor and is receiving an epidural for pain relief. Which of the following should the nurse monitor as the priority?

Correct answer: B

Rationale: The most common side effect of an epidural is hypotension, which can compromise placental perfusion. Monitoring the client's blood pressure is the priority to ensure maternal and fetal well-being. Fetal heart rate is important but monitoring the client's blood pressure takes precedence due to the risk of hypotension. Respiratory rate and pain level monitoring are also important but not the priority in this scenario.

2. A nurse is preparing to administer an enteral tube feeding through an NG tube at 250 mL over 4 hr. The nurse should set the pump to deliver how many mL/hr?

Correct answer: C

Rationale: Calculation: 250 mL / 4 hours = 62.5 mL/hr, which should be rounded up to 63 mL/hr. This ensures the correct rate is set for continuous feeding. Choice A (60 mL/hr) is incorrect as it does not reflect the accurate calculation. Choice B (62 mL/hr) is close but does not round up to the nearest whole number as required. Choice D (65 mL/hr) is higher than the correct calculation and would deliver the feeding solution at a faster rate than prescribed.

3. A nurse is caring for a client prescribed digoxin. Which of the following should alert the nurse to possible digitalis toxicity?

Correct answer: A

Rationale: Corrected Rationale: Digitalis toxicity is a serious complication of digoxin therapy, particularly in older adults. Early symptoms include anorexia, nausea, and generalized weakness. Anorexia and weakness are common indicators of digitalis toxicity. Hyperactivity, hunger, tachycardia, increased urination, polyphagia, and polydipsia are not typical signs of digitalis toxicity. Monitoring for anorexia and weakness can help detect toxicity early and prevent life-threatening arrhythmias.

4. A nurse is in an acute care facility, caring for a client who is postop following abdominal surgery. Which behavior should the nurse identify as increasing the client's risk for constipation?

Correct answer: B

Rationale: The correct answer is B: 'Suppression of the urge to defecate.' Suppressing the urge to defecate can lead to constipation, especially in postoperative clients. It is essential to encourage clients to respond to the urge to defecate to prevent constipation. Increased fiber intake (Choice A) is beneficial for preventing constipation. Ambulation (Choice C) helps promote bowel motility and can reduce the risk of constipation. Daily laxative use (Choice D) may contribute to laxative dependence but is not the behavior most directly associated with increasing the risk of constipation in this scenario.

5. In the nursing process, the evaluation phase is used to determine:

Correct answer: D

Rationale: The evaluation phase of the nursing process is used to determine the degree of outcome achievement. It assesses whether the goals and outcomes set during the planning phase were met. Choice A is incorrect because it focuses on the worth of the intervention rather than the achievement of outcomes. Choice B is incorrect as it pertains to the assessment phase where problems are identified. Choice C is incorrect as it refers to the planning phase where the care plan is developed, not evaluated.

Similar Questions

A nurse is caring for a client receiving a dopamine infusion via a peripheral IV. Which of the following actions should the nurse take if the IV site appears infiltrated?
A nurse is preparing to administer a dose of insulin. Which of the following should the nurse do first?
A nurse in a clinic is caring for a patient who has a UTI. What prescription should the nurse verify with a provider?
A nurse is performing a vaginal exam on a client who is in active labor. The nurse notes the umbilical cord protruding through the cervix. Which of the following actions should the nurse take?
A nurse is caring for a client with a history of substance abuse. Which of the following interventions should the nurse prioritize?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses