Nokea
The nurse is caring for a woman with epidural anesthesia for pain control during a vaginal delivery. A risk for injury related to epidural anesthesia has been identified by the nursing staff. What interventions are appropriate for the nurse to implement related to this diagnosis? (Select all that apply.)
- A. Assess leg movement and sensation before ambulating.
- B. Administer antibiotic as ordered.
- C. Observe for signs of impending birth.
- D. Provide sacral pressure as needed.
- E. Assess fetal position frequently.
Correct Answer: A,C
Rationale: To prevent the risk for injury related to epidural anesthesia, the nurse should assess for movement, sensation, and leg strength before ambulating, ambulate cautiously with an assistant, assist the woman to change positions regularly, and observe for signs that birth may be near: increase in bloody show, perineal bulging, and/or crowning.
You may also like to solve these questions
Which position(s) and exercise(s) will the nurse teach as beneficial in combating discomfort in the later stages of pregnancy? (Select all that apply.)
- A. Leg lifts
- B. Pelvic rock
- C. Tailor sitting
- D. Sit-ups
- E. Shoulder curling
Correct Answer: B,C,E
Rationale: Pelvic rock, tailor sitting, and shoulder curling are beneficial to the muscles that will have to adapt to the extra weight and changed posture of later pregnancy. Leg lifts and sit-ups are not beneficial, because they both increase intra-abdominal pressure.
A woman requests a pudendal block to manage her labor pain. What statement by the woman indicates a need for further explanation about the pudendal block?
- A. I'm having a contraction. Can I get the pudendal block now?'
- B. I'll get the pudendal block right before I deliver.'
- C. The nurse-midwife will insert the needles into my vagina.'
- D. It takes a few minutes after the medicine is administered to make me feel numb.'
Correct Answer: A
Rationale: The pudendal block does not block pain from contractions and is given just before birth.
What would the nurse guide a labor coach to do to comfort a woman tensing her muscles with contractions?
- A. Offer warm liquids to the patient.
- B. Encourage the patient to pant.
- C. Engage the patient in conversation.
- D. Assist the patient to the knee-chest position.
Correct Answer: B
Rationale: Panting relaxes the abdominal wall and distracts the patient. It would not be helpful to offer fluids or to attempt conversation during contractions.
The nurse is providing a conference on nonpharmacological pain control methods. What major advantages of nonpharmacological pain control methods will the nurse include in the presentation? (Select all that apply.)
- A. They sedate the mother.
- B. They do not slow labor.
- C. They do not dull the excitement of the birth experience.
- D. They do not have the potential to cause allergic reactions.
- E. They do not have to be delayed until labor is well established.
Correct Answer: B,C,D,E
Rationale: All the options mentioned are benefits of nonpharmacological pain control methods with the exception of sedating the mother.
The physician has ordered Fentanyl (Sublimaze) for a woman in labor and has asked the nurse to provide patient education. What will the nurse include in the educational plan? (Select all that apply.)
- A. Onset is slow.
- B. Duration is short.
- C. Administration is by mouth.
- D. No known side effects.
- E. It is not the same drug as sufentanil.
Correct Answer: B,E
Rationale: Fentanyl has a rapid onset and short duration of action. Fentanyl, sufentanil, and alfentanil are not the same drugs. Fentanyl can cause respiratory depression but less than meperidine. It is not administered by mouth.