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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?

A.

Monitor the client's vital signs every hour following the procedure.

B.

Review the client's platelet count level prior to the procedure.

C.

Inform the client that their bladder should be full before the procedure.

D.

Obtain the client's consent following the procedure.

Answer and Explanation

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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Related Questions

Correct Answer is ["A","B","C","E","F"]

Explanation

Rationale for Correct Choices:

  • Pain radiating to the back, worsens after eating or lying down: This is characteristic of acute pancreatitis, where inflammation irritates surrounding tissues and worsens in the supine position due to gravitational pressure. Postprandial worsening suggests pancreatic enzyme stimulation.
  • Scleral icterus (yellow sclera and palate): Jaundice suggests biliary obstruction or liver involvement, possibly due to gallstone pancreatitis or alcoholic liver disease. This also aligns with the elevated bilirubin levels and warrants further hepatic and biliary assessment.
  • Abdomen distended, rigid, and tender with guarding: These are signs of peritonitis or severe intra-abdominal inflammation, requiring urgent evaluation. Guarding and rigidity indicate localized or diffuse peritoneal irritation from pancreatic enzymes.
  • Hypoactive bowel sounds: Reduced bowel activity is often seen in pancreatitis due to paralytic ileus caused by inflammation and stress response. Monitoring for progression to ileus or obstruction is necessary.
  • Client guards abdomen and grimaces during palpation: Guarding and pain upon palpation are signs of significant intra-abdominal inflammation. It may reflect worsening pancreatitis or complications such as necrosis or peritonitis.

Rationale for Incorrect Choices:

  • Heart rate regular, lungs clear to auscultation: These are normal findings and do not require follow-up.
  • Client is alert and oriented x4: Indicates normal neurologic status. No immediate concern here.
  • Reports no recent illnesses, takes no prescribed medications: This helps rule out medication-induced pancreatitis and doesn't indicate a need for follow-up.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B,C"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

Rationale:

  • Hypercapnia: This is a hallmark of malignant hyperthermia (MH), resulting from uncontrolled calcium release in muscle cells leading to increased metabolism and CO2 production. It is not typical of latex allergy or hypovolemic shock. Neither condition causes increased carbon dioxide retention from muscle metabolism.
  • Tachycardia: Elevated heart rate is common in MH due to hypermetabolic state, in latex allergy as part of anaphylaxis response, and in hypovolemic shock as a compensatory mechanism for decreased circulating volume.
  • Wheezing: Wheezing reflects bronchospasm, a common feature of latex allergy/anaphylaxis, but is not a symptom of MH or hypovolemic shock.
  • Urticaria (hives): Urticaria is a typical allergic skin reaction seen in latex allergy but is absent in MH and hypovolemic shock.
  • Muscle rigidity: Muscle rigidity, particularly jaw muscle rigidity (masseter spasm), is a classic sign of MH due to abnormal muscle metabolism. This finding is not associated with latex allergy or hypovolemic shock.

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