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 A

Explanation

A. Orange slices: Vitamin C-rich foods like oranges significantly enhance the absorption of nonheme iron found in plant-based diets. This makes them an ideal recommendation for vegetarians needing increased iron intake.
B. Cheddar cheese: Dairy products contain calcium, which can actually inhibit iron absorption, making this an unhelpful choice for enhancing iron uptake.
C. Boiled eggs: While eggs contain some iron, they do not enhance the absorption of nonheme iron and may contain components that slightly interfere with its absorption.
D. Mixed nuts: Although they provide some nonheme iron, they do not improve its absorption. They lack vitamin C and are not effective enhancers on their own.

A. Check gastric residuals every 4 hr. B. Ensure the formula is cold before administration. C. Check placement of the feeding tube x-ray once daily. D. Change the feeding container and tubing every 24 hr. E. Maintain the head of the clients bed at a 30o angle or higher.

Correct Answer is ["A","D","E"]

Explanation

A. Check gastric residuals every 4 hr: Monitoring gastric residual volume every 4 hours helps assess tolerance to the feeding and prevents aspiration or overfeeding.
B. Ensure the formula is cold before administration: Cold formula can cause gastric cramping and discomfort. It should be at room temperature prior to administration.
C. Check placement of the feeding tube x-ray once daily: X-ray confirmation is typically done once upon initial insertion. Daily checks are not required unless there’s a concern about displacement.
D. Change the feeding container and tubing every 24 hr: This reduces the risk of bacterial contamination, especially since enteral nutrition provides a medium for microbial growth.
E. Maintain the head of the client’s bed at a 30° angle or higher: Elevating the head of the bed helps prevent aspiration by keeping gastric contents from refluxing into the esophagus.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing prenatal teaching about iron to a client who follows a vegetarian diet. The nurse should recommend that the client consume which of the following foods to enhance the absorption Of nonheme iron?

Correct Answer is A

Explanation

A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

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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.