A client who is a primigravida at 40 weeks gestation is contracting every 2 minutes and her cervix is 9 cm dilated and 100% effaced. The fetal heart rate is 120 beats/minute. The client is screaming and her husband is alarmed. Which intervention should the practical nurse (PN) implement?
Call the rapid response team to the bedside.
Check the time the last PRN narcotic analgesic was given.
Report to charge nurse that the client is near to delivery.
Ask the husband to leave the room for a while.
The Correct Answer is C
The practical nurse should report to the charge nurse that the client is near delivery, as the client's signs indicate that she is in the transition phase of labor and is likely to deliver soon. The PN should also assess the client's vital signs, fetal heart rate, and pain level, and prepare the delivery equipment.
The husband can be asked to provide emotional support to the client during labor.
The rapid response team may be called in case of a medical emergency, but this is not indicated based on the information given.
Checking the time, the last PRN narcotic analgesic was given is also not indicated at this point, as the client is close to delivery and may not have time for medication to take effect.
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Correct Answer is B
Explanation
The greatest priority for the practical nurse to monitor during the administration of epidural anesthesia is maternal blood pressure (BP). Epidural anesthesia can cause maternal hypotension due to vasodilation and decreased venous return, which can result in decreased fetal perfusion and oxygenation. Therefore, it is important for the practical nurse to monitor maternal BP frequently and promptly report any significant changes to the healthcare provider. Options A, C, and D are also important assessments, but they are not the priority in this scenario.
Therefore, options A, C, and D are not answers because they are not the priority assessment during the administration of epidural anesthesia.
Correct Answer is A
Explanation
The practical nurse (PN) should ask the client if he is planning to obey the voices, as this will help determine the client's risk for harming himself or others. The PN should also ask about the onset and duration of the symptoms and any factors that may have triggered them, such as drug use or recent stressors. Additionally, the PN should assess the client's perception of the voices, as some individuals may recognize them as a symptom of a mental illness, while others may believe them to be real. It is important for the PN to remain non-judgmental and supportive during the assessment, while prioritizing the client's safety.
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