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.

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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Correct Answer is B

Explanation

Rationale:

A. A client who reports a sudden onset of dizziness when sitting up: Although concerning, dizziness on position change may indicate orthostatic hypotension and is not immediately life-threatening. This client requires monitoring but is not the top priority based on airway or circulatory compromise.

B. A client who has new onset urticaria and angioedema: New urticaria and angioedema suggest a potential anaphylactic reaction, which can quickly progress to airway obstruction. This is a life-threatening emergency requiring immediate intervention to secure the airway and administer epinephrine.

C. A client who has numerous rectal polyps and blood-tinged stools: This condition could indicate a colorectal condition such as polyposis or malignancy, but it is not acutely life-threatening. The client needs evaluation, but not before those with airway or circulatory risks.

D. A client who has a subluxation of the fifth digit on the left foot: A subluxation is a partial dislocation, which can be painful but does not involve vital organ systems. This musculoskeletal issue is stable and can be addressed after more urgent needs are met.

A. 0.45% saline B. Glargine insulin C. 4.9% normal saline D. NPH insulin

Correct Answer is A

Explanation

Rationale:

A. 0.45% saline: After initial fluid resuscitation with 0.9% saline, clients with diabetic ketoacidosis (DKA) are often transitioned to 0.45% saline to provide ongoing volume replacement while avoiding sodium overload. This hypotonic solution helps correct dehydration without worsening hypernatremia.

B. Glargine insulin: Glargine is a long-acting insulin given subcutaneously and is not appropriate for continuous IV infusion. In DKA, rapid insulin action is necessary to reduce blood glucose and suppress ketogenesis quickly.

C. 4.9% normal saline: There is no such recognized concentration as 4.9% normal saline. Standard saline solutions used clinically include 0.9% (isotonic) and 0.45% (hypotonic), making this an incorrect and potentially unsafe option.

D. NPH insulin: NPH is an intermediate-acting insulin used for long-term glycemic control, not for acute management of DKA. It is given subcutaneously and has a delayed onset, making it unsuitable for continuous IV infusion.

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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?

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