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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Related Questions
Correct Answer is C
Explanation
Rationale:
A. Emphasize vowel sounds when speaking: Vowel sounds are not as difficult to hear as consonants, especially for clients with sensorineural hearing loss. Overemphasizing vowel sounds can distort speech and make understanding more difficult.
B. Lower the tone of voice at the end of each sentence: Lowering the tone may cause parts of the message to be missed, especially if the client relies on lip-reading or residual hearing. A consistent tone and clear enunciation are more effective communication strategies.
C. Decrease background noise when talking with the client: Reducing background noise improves the client’s ability to focus on the speaker and hear more clearly. Background noise can interfere with hearing aids and make communication more challenging for individuals with hearing impairment.
D. Sit next to the client when speaking to them: Sitting next to the client may reduce their ability to see facial expressions or lip-read. It is more effective to sit directly in front of them and maintain eye contact to facilitate clear communication.
Correct Answer is D
Explanation
Rationale:
A. Remove the safety inspection sticker before plugging in the IV pump: The safety inspection sticker confirms that the device has passed required safety checks. It should remain visible to indicate the equipment is safe for use and up to date with biomedical inspections.
B. Ensure that the electric outlet has two prongs for the IV pump: Medical devices like IV pumps should be plugged into grounded three-prong outlets to reduce the risk of electrical shock. Two-prong outlets are not suitable for hospital-grade equipment.
C. Grasp the IV pump cord when unplugging it from the electrical outlet: Pulling on the cord instead of the plug can damage the wiring and increase the risk of electrical hazard or equipment failure. The plug itself should be held when disconnecting from the outlet.
D. Check the cords of the IV pump for fraying: Inspecting cords for damage such as fraying is a critical safety check before use. Damaged cords pose a serious fire and shock risk and should be reported and repaired before using the device.
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