A nurse is caring for a client in active labor.

Exhibits

The nurse is assuming care for the client at 0305. For each nursing action, click to specify if the nursing action is essential or contraindicated for the client.

Assist the client with ambulation.

Monitor for elevated temperature.

Inform the client to expect drowsiness.

Assess for urinary retention.

Encourage the client to turn from side to side.

Answer and Explanation

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

Rationale for Essential Actions:

Monitor for elevated temperature: Epidural anesthesia can increase the risk of maternal fever due to decreased peripheral heat loss. Monitoring temperature helps detect infection or epidural-related hyperthermia early.
Assess for urinary retention:Epidural anesthesia can impair bladder sensation and motor control, making urinary retention common. Ongoing bladder assessments are crucial to prevent bladder distention and associated labor complications.
Encourage the client to turn from side to side: Repositioning promotes fetal descent and optimal uteroplacental perfusion, and helps prevent supine hypotension by avoiding vena cava compression in laboring women.

Rationale for Contraindicated Actions:

Assist the client with ambulation: Epidural anesthesia impairs lower extremity motor function and balance, posing a high fall risk. Bedrest is required after epidural placement unless sensation and motor function are fully restored and evaluated.
Inform the client to expect drowsiness: Drowsiness is not a typical or expected effect of epidural anesthesia. Sedation may indicate systemic effects or complications and should not be presented as expected.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Remind the client to eat scheduled meals daily: At the end of life, appetite often decreases, and forcing scheduled meals can cause discomfort. Encouraging small, preferred foods as tolerated is more appropriate.
B. Offer the client a blanket to keep warm: Clients nearing end of life often experience cold intolerance due to decreased circulation and metabolism. Providing warmth helps maintain comfort and dignity.
C. Speak in a loud tone when addressing the client: Speaking loudly can be perceived as disrespectful or frightening, especially if the client is confused or hearing impaired. A calm, gentle tone is more supportive.
D. Place the client in a supine position: The supine position may increase discomfort or breathing difficulties in some terminal clients; positioning should focus on comfort and ease of breathing, often semi-Fowler’s or side-lying

A. Aspirin 1 tablet daily B. Metoprolol 5 mg IV now C. Furosemide 20 mg BID D. Nitroglycerin transdermal patch

Correct Answer is B

Explanation

A. Aspirin 1 tablet daily: This prescription is incomplete because it does not specify the dosage in milligrams or the route of administration, which are essential for safe medication administration.
B. Metoprolol 5 mg IV now: This is a complete prescription as it includes the medication name, exact dosage (5 mg), route (IV), and timing (now), meeting all criteria for safe administration.
C. Furosemide 20 mg BID: Although the dose and frequency are included, the prescription is incomplete without specifying the route (e.g., oral or IV), which is necessary for clarity and safety.
D. Nitroglycerin transdermal patch: This order is incomplete as it does not include the dosage, frequency of application, or duration of use, all of which are critical components of a complete prescription.

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A nurse is caring for a client in active labor. Exhibits The nurse is assuming care for the client at 0305. For each nursing action, click to specify if the nursing action is essential or contraindicated for the client.

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A nurse is caring for a client in active labor.

Exhibits

The nurse is assuming care for the client at 0305. For each nursing action, click to specify if the nursing action is essential or contraindicated for the client.