A nurse is assisting with the initiation of epidural analgesia for a client who is in the second stage of labor. Which of the following actions should the nurse take?
Monitor the client's vital signs every hour following the procedure.
Review the client's platelet count level prior to the procedure.
Inform the client that their bladder should be full before the procedure.
Obtain the client's consent following the procedure.
The Correct Answer is B
Rationale:
A. Monitor the client's vital signs every hour following the procedure: Vital signs, especially blood pressure, should be monitored more frequently—usually every 5 to 15 minutes immediately after epidural initiation—to assess for hypotension, a common complication.
B. Review the client's platelet count level prior to the procedure: A low platelet count increases the risk of epidural hematoma during needle insertion. Reviewing coagulation status is essential to ensure it's safe to proceed with epidural placement.
C. Inform the client that their bladder should be full before the procedure: The bladder should be emptied, not full, prior to the procedure. A full bladder increases discomfort, impairs fetal descent, and may lead to urinary retention after the epidural is placed.
D. Obtain the client's consent following the procedure: Informed consent must be obtained before any invasive procedure, including epidural anesthesia. Performing the procedure without prior consent violates patient autonomy and legal standards.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A,B"}}
Explanation
Rationale:
- Excessive spending habits: This behavior is hallmark for mania, where impaired judgment, impulsivity, and inflated self-esteem lead to reckless financial decisions.
- Hallucinations: Hallucinations, especially visual or auditory ones, are classic signs of psychosis. They indicate a break from reality and are not a diagnostic feature of mania alone unless psychotic features are present.
- Pressured speech: Pressured, rapid, and loud speech is a diagnostic feature of mania, reflecting heightened psychomotor activity and racing thoughts.
- Lack of sleep: Insomnia without fatigue is typical in mania. Clients may stay awake for days with increased energy levels and no perceived need for rest.
- Disorganized thought process: This can appear in both mania and psychosis. In mania, it stems from flight of ideas and distractibility. In psychosis, it results from impaired reality testing and cognitive disintegration.
Correct Answer is ["200"]
Explanation
Calculation:
Total volume to be infused = 100 mL.
- Convert the infusion time from minutes to hours.
Infusion time = 30 min / 60 min/hr
= 0.5 hr.
- Calculate the infusion rate in milliliters per hour (mL/hr).
Infusion rate (mL/hr) = Total volume (mL) / Infusion time (hr)
= 100 mL / 0.5 hr
= 200 mL/hr.
Answer: 200 mL/hr
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