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.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is A,B,D,C

Explanation

A. The first priority is to rescue any individuals in immediate danger. Moving the client ensures their safety before addressing the fire. Delaying this step could expose the client to smoke inhalation or burns.

B. Once the client is safe, the nurse must activate the fire alarm system. This alerts the rest of the facility and triggers the emergency response protocol. Early alarm activation helps prevent the fire from spreading further.

C. Attempting to extinguish the fire comes only after other safety measures. If the fire is small and controllable, using a fire extinguisher may prevent escalation. However, it must only be attempted when it is safe to do so.

D. Closing nearby windows and doors helps contain the fire to one area. This reduces oxygen flow and slows the spread of fire and smoke throughout the unit. Containment is a key step in minimizing damage and injury.

A. Warm the irrigation solution. B. Perform the Credés maneuver. C. Replace the indwelling urinary catheter D. Maintain the irrigation solution rate.

Correct Answer is D

Explanation

A. Warm the irrigation solution: While warming may enhance comfort, it does not impact the color of urine or address post-procedure bleeding. It is not a necessary intervention in this situation.
B. Perform the Credé's maneuver: This technique, which involves manual pressure over the bladder, is used for clients with neurogenic bladder or urinary retention. It is not appropriate during continuous bladder irrigation.
C. Replace the indwelling urinary catheter: Catheter replacement would only be considered if there was a complete blockage that couldn't be cleared, severe kinking, or signs of infection, none of which are indicated here. Replacing the catheter unnecessarily increases the risk of trauma and infection.
D. Maintain the irrigation solution rate: Pink-tinged urine is expected within the first few hours following TURP as a result of minor bleeding. Continuing irrigation at the current rate helps prevent clot formation and maintains catheter patency.

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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

28. A nurse enters a client's room and sees a small fire in the client's bathroom. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps) (ORDERED RESPONSE)

Correct Answer is A,B,D,C

Explanation

A nurse is assessing a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate 4 hr ago. The nurse notes pink-tinged urine in the drainage bag. Which of the following actions should the nurse take?

Correct Answer is D

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.