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 C
Explanation
Rationale:
A. Veracity: Veracity involves telling the truth and providing accurate information. While important in building trust, it is not the ethical principle most relevant to offering emotional presence during grief.
B. Fidelity: Fidelity refers to being faithful to promises and responsibilities, including maintaining confidentiality and following through on care. It does not specifically reflect the act of offering comfort in grief.
C. Beneficence: Beneficence is the act of doing good and promoting the well-being of others. By sitting with the grieving client to provide comfort, the nurse is demonstrating compassion and aiming to alleviate suffering.
D. Autonomy: Autonomy refers to respecting a client’s right to make their own decisions regarding care. While essential in healthcare, it does not directly relate to the nurse’s compassionate presence during bereavement.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}
Explanation
Rationale:
- Prenatal anemia: Anemia may impair immune function and tissue oxygenation, making the postpartum client more vulnerable to infections such as endometritis, especially after cesarean delivery.
- Polyhydramnios: Excessive amniotic fluid stretches the uterus beyond normal capacity, which can impair uterine contractility postpartum, increasing the risk of uterine atony and resulting in subinvolution or hemorrhage.
- High parity: Multiple previous pregnancies lead to uterine muscle fatigue, reducing tone and contractility, which predisposes the uterus to poor involution and increases the risk of uterine atony.
- Prolonged rupture of membranes: A rupture lasting more than 18 hours increases the risk of ascending bacterial infection and is a significant risk factor for postpartum endometritis or chorioamnionitis.
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