A nurse is assisting with the care of a client who is receiving epidural anesthesia for pain management during labor. Which of the following actions should the nurse take?
Remind the client to void every 4 hr.
Encourage the client to alternate from side to side every 2 hr.
Raise the four side rails on the client's bed.
Monitor the client's blood pressure.
The Correct Answer is D
Choice A reason:
The nurse should not remind the client to void every 4 hours because epidural anesthesia can cause temporary loss of bladder sensation, making it difficult for the client to know when to void. Instead, the nurse should use a bladder scanner to assess for urinary retention and encourage the client to void regularly.
Choice B reason:
Encouraging the client to alternate from side to side every 2 hours is not directly related to the administration of epidural anesthesia. This action is commonly advised for clients who are on bed rest to prevent pressure ulcers and promote circulation. However, it is not specifically necessary for the client receiving epidural anesthesia for pain management during labor.
Choice C reason:
Raising the four side rails on the client's bed is not necessary in this situation. The use of side rails should be based on the client's mobility and risk assessment for falls. If the client is receiving epidural anesthesia, they may experience reduced mobility, but the decision to use side rails should be made on an individual basis, not solely based on the anesthesia.
Choice D reason:
Monitoring the client's blood pressure is a crucial action when a client is receiving epidural anesthesia. Epidural anesthesia can cause a drop in blood pressure, leading to hypotension. By regularly monitoring the client's blood pressure, the nurse can detect any significant changes and take appropriate actions to maintain hemodynamic stability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
"I should start trying to breastfeed within an hour of having my baby.” Choice A reason:
The client's statement indicates an understanding of the teaching because initiating breastfeeding within the first hour after birth is crucial for successful breastfeeding. This early initiation allows the baby to receive colostrum, which is rich in nutrients and antibodies, supporting the baby's immune system and providing essential nutrition during the initial stages of life. Additionally, early breastfeeding helps establish a strong bond between the mother and the baby while promoting the baby's suckling reflex.
Choice B reason:
The statement in Choice B is incorrect. Formula feeding between breastfeedings is not recommended in the early stages of breastfeeding, especially if the baby loses 5 percent of their birth weight. Newborns often lose some weight initially, which is normal, and it can be regained through effective breastfeeding. Supplementing with formula may interfere with establishing a good milk supply and the baby's ability to latch properly.
Choice C reason:
This statement in Choice C is incorrect. During breastfeeding sessions, it's essential for the baby to nurse on one breast fully before switching to the other breast. Allowing the baby to nurse for at least 10-15 minutes on each breast ensures they receive the hindmilk, which is higher in fat and essential for the baby's growth and development.
Choice D reason:
The statement in Choice D is incorrect. Offering a pacifier right after breastfeeding might interfere with the baby's feeding cues and lead to decreased breastfeeding frequency.
Newborns may suck for non-nutritive reasons, and offering a pacifier too soon can hinder proper breastfeeding establishment, as they may satisfy their sucking needs with the pacifier rather than nursing at the breast.
Correct Answer is A
Explanation
The nurse should maintain continuous observation of the adolescent.
Choice A reason:
The first and most crucial action when a patient expresses an intention to self-harm is to ensure their safety. By maintaining continuous observation, the nurse can closely monitor the adolescent's behavior and intervene promptly if any signs of self-harm emerge. This action helps prevent immediate harm and allows for timely interventions.
Choice B reason:
Applying wrist restraints to the adolescent (Choice B) would not be appropriate in this situation. Restraints are typically used as a last resort for patients who pose a danger to themselves or others and only when less restrictive measures have failed. In the case of self- harm, using restraints can increase the patient's distress and potentially worsen the situation.
Choice C reason:
Collecting data about the adolescent's mental status (Choice C) is an essential step in understanding their overall condition, but it should not be the first action taken. While gathering data is important for a comprehensive assessment, immediate safety concerns must take precedence.
Choice D reason:
Obtaining consent from the adolescent's guardian for the application of restraints (Choice D) is not the first priority when the patient expresses an intention to self-harm. The focus should be on ensuring the patient's immediate safety, and consent for restraints may be necessary only if other interventions prove inadequate.
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