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 C

Explanation

Rationale:

A. Tinnitus: Tinnitus is not a known or common adverse effect of clozapine. While it may indicate another condition, it does not require immediate reporting in the context of clozapine therapy.

B. Dizziness: Dizziness can occur due to clozapine’s hypotensive effects, especially when initiating therapy. It is usually self-limiting and managed symptomatically unless it worsens or affects safety.

C. Sore throat: A sore throat can signal the onset of agranulocytosis, a life-threatening side effect of clozapine marked by a dangerously low white blood cell count. It must be reported immediately for prompt blood count evaluation.

D. Diaphoresis: Diaphoresis may occur with many medications and is not specific to clozapine toxicity or serious adverse effects. It typically does not warrant immediate reporting unless severe or part of a broader concerning symptom complex.

A. Hyperthyroidism B. Hypocalcemia C. Thrombophlebitis D. Diverticulosis

Correct Answer is C

Explanation

Rationale:

A. Hyperthyroidism: While hyperthyroidism requires medical management, it is not a contraindication to the use of combination oral contraceptives (COCs). Hormonal contraception can generally be used safely with thyroid disorders under monitoring.

B. Hypocalcemia: Low calcium levels are not influenced significantly by COCs and do not increase the risk of adverse outcomes with their use. Therefore, hypocalcemia is not considered a contraindication.

C. Thrombophlebitis: Thrombophlebitis, a condition involving blood clots and vein inflammation, is a major contraindication to COCs. Estrogen increases the risk of thromboembolic events, making COCs unsafe for clients with current or past clotting disorders.

D. Diverticulosis: Diverticulosis is an intestinal condition not impacted by hormonal contraceptive use. It does not increase the risk of complications related to COCs and is not a contraindication.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is taking clozapine. Which of the following findings should the nurse report to the provider?

Correct Answer is C

Explanation

A nurse is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client's history is a contraindication to the use of combination oral contraceptives?

Correct Answer is C

Explanation

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