Nokea
A client in labor requests epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?
- A. Position the client supine for 30 minutes after the first dose of anesthetic solution.
- B. Administer 1,000 mL of dextrose 5% in water after the first dose of anesthetic solution.
- C. Monitor the client's blood pressure every 5 minutes after the first dose of anesthetic solution.
- D. Ensure the client has been NPO for 4 hours before the placement of the epidural and the first dose of anesthetic solution.
Correct Answer: C
Rationale: The correct answer is C: Monitor the client's blood pressure every 5 minutes after the first dose of anesthetic solution. This is crucial as epidural anesthesia can cause hypotension, which can lead to maternal and fetal complications. Monitoring blood pressure every 5 minutes allows for early detection and intervention.
A: Positioning the client supine for 30 minutes after the first dose of anesthetic solution can lead to hypotension due to decreased venous return, so this is incorrect.
B: Administering dextrose 5% in water is not a standard practice after epidural anesthesia and does not address the risk of hypotension, so this is incorrect.
D: Ensuring the client has been NPO for 4 hours before the procedure is important for general anesthesia but not specifically for epidural anesthesia, so this is incorrect.
You may also like to solve these questions
A client is postpartum and has idiopathic thrombocytopenic purpura (ITP). Which of the following findings should the nurse expect?
- A. Decreased platelet count
- B. Increased erythrocyte sedimentation rate (ESR)
- C. Decreased megakaryocytes
- D. Increased WBC
Correct Answer: A
Rationale: Step 1: In idiopathic thrombocytopenic purpura (ITP), there is a decreased platelet count due to immune-mediated destruction of platelets.
Step 2: This leads to an increased risk of bleeding and bruising in the postpartum client.
Step 3: Other choices are incorrect because in ITP, there is no increase in ESR or WBC. Also, megakaryocytes may be normal or increased due to compensatory production.
A parent is receiving discharge teaching from a nurse regarding caring for their newborn after a circumcision. Which instruction should the nurse include?
- A. Apply slight pressure with a sterile gauze pad for mild bleeding.
- B. Inspect the circumcision site every 6 to 8 hours.
- C. Avoid using baby wipes containing alcohol to cleanse the penis with each diaper change.
- D. Clean the circumcision site daily using a warm, wet washcloth.
Correct Answer: A
Rationale: The correct answer is A: Apply slight pressure with a sterile gauze pad for mild bleeding. This instruction is crucial because it addresses the immediate post-circumcision care to control bleeding. Applying slight pressure with a sterile gauze pad helps to promote clotting and prevent excessive bleeding. This step is essential to ensure the newborn's safety and prevent complications.
Summary of other choices:
B: Inspecting the circumcision site every 6 to 8 hours is important, but not as critical as addressing bleeding promptly.
C: Avoiding baby wipes containing alcohol is a good practice to prevent irritation, but it is not the most urgent instruction for immediate care.
D: Cleaning the circumcision site daily using a warm, wet washcloth is generally recommended for routine care, but in the immediate post-circumcision period, controlling bleeding takes precedence.
A client in active labor reports back pain while being examined by a nurse who finds her to be 8 cm dilated, 100% effaced, -2 station, and in the occiput posterior position. What action should the nurse take?
- A. Perform effleurage during contractions.
- B. Place the client in lithotomy position.
- C. Assist the client to the hands and knees position.
- D. Apply a scalp electrode to the fetus.
Correct Answer: C
Rationale: The correct action is to assist the client to the hands and knees position. This position, also known as the all-fours position, can help alleviate back pain by encouraging the baby to rotate into a more favorable position for delivery. By being on hands and knees, gravity assists in the rotation of the baby. This position can also help relieve pressure on the mother's back and potentially facilitate a smoother labor progress. Effleurage (choice A) may provide comfort but doesn't address the positional issue. Placing the client in lithotomy position (choice B) can worsen the occiput posterior position. Applying a scalp electrode to the fetus (choice D) is not indicated in this scenario.
A client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?
- A. Check the client's temperature.
- B. Observe for uterine contractions.
- C. Administer Rho(D) immune globulin.
- D. Monitor the fetal heart rate (FHR).
Correct Answer: D
Rationale: The correct answer is D: Monitor the fetal heart rate (FHR). After an amniocentesis, the priority is monitoring FHR to assess fetal well-being and detect any signs of distress. This is crucial as the procedure carries a risk of causing fetal distress. Checking the client's temperature (A) is important but not the priority. Observing for uterine contractions (B) is important but not immediate post-amniocentesis. Administering Rho(D) immune globulin (C) is typically done in cases of Rh incompatibility and not directly related to the amniocentesis procedure.
When educating a pregnant client about potential complications, which manifestation should the nurse emphasize reporting to the provider promptly?
- A. Vaginal bleeding
- B. Swelling of the ankles
- C. Heartburn after eating
- D. Lightheadedness when lying on back
Correct Answer: A
Rationale: The correct answer is A: Vaginal bleeding. This is crucial to report promptly as it could indicate serious issues like placental abruption or miscarriage. Swelling of the ankles (B) is common in pregnancy but not typically an urgent concern. Heartburn (C) is common and can be managed with lifestyle changes. Lightheadedness when lying on the back (D) is likely due to inferior vena cava compression and can be relieved by changing position. Reporting vaginal bleeding is vital for timely intervention in pregnancy complications.