A nurse is caring for a client in active labor.
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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Prime the tubing with 0.9% sodium chloride: Normal saline is the only compatible solution used to prime blood transfusion tubing. It prevents clotting or hemolysis and ensures that blood components are not damaged during administration.
B. Attach a single-line administration set: A Y-type or dual-line administration set with a filter is required for safe transfusion. Single-line sets do not allow simultaneous saline flushing, which is necessary during transfusion to prevent clotting and maintain patency.
C. Use an IV catheter that is at least 24 gauge: While a 24-gauge catheter can be used in pediatric clients, adults require at least an 18–20 gauge catheter to prevent hemolysis and ensure rapid infusion of blood products when needed.
D. Use tubing that does not have a filter in the drip chamber: Blood administration sets must include a filter to trap clots and debris. Using tubing without a filter increases the risk of transfusion-related complications such as embolism or febrile reactions.
Correct Answer is B
Explanation
A. Ibuprofen: This NSAID can irritate the gastric lining and increase the risk of bleeding, making it inappropriate for clients with a history of peptic ulcers.
B. Acetaminophen: It is not an NSAID and does not affect the gastrointestinal lining, making it a safer option for pain relief in clients with peptic ulcer disease.
C. Ketorolac: Like other NSAIDs, ketorolac increases the risk of gastric bleeding and should be avoided in clients with peptic ulcers.
D. Aspirin: Aspirin is an NSAID and antiplatelet agent that can worsen peptic ulcers and increase bleeding risk, so it should not be used in this client.
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