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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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. Abdominal aortic aneurysm: While this condition is serious, it does not directly affect the safety of applying localized heat therapy to a distal site like the foot, unless systemic complications are present.
B. Osteoarthritis: Heat therapy is often beneficial in osteoarthritis, as it helps reduce joint stiffness and improve circulation to the affected area, making it a common and safe intervention.
C. Phlebitis: Warm compresses are sometimes used in phlebitis to reduce inflammation and promote comfort, provided there are no signs of infection or severe vascular compromise.
D. Peripheral neuropathy: Clients with peripheral neuropathy have impaired sensation and may not feel excessive heat, increasing the risk of burns or tissue injury. This makes heat therapy unsafe for these individuals.

A. Irritability B. Impulsivity C. Takes advantage of others D. Shows perfectionism

Correct Answer is D

Explanation

A. Irritability: While clients with obsessive-compulsive personality disorder (OCPD) may become frustrated when things are not done their way, persistent irritability is more characteristic of mood or anxiety disorders rather than a core feature of OCPD.
B. Impulsivity: Impulsivity is typically associated with borderline or antisocial personality disorders. Clients with OCPD are generally rigid, controlled, and rule-bound rather than impulsive.
C. Takes advantage of others: This behavior is more aligned with antisocial personality disorder. Clients with OCPD are often rule-abiding and conscientious, though they may be excessively controlling or critical.
D. Shows perfectionism: Perfectionism is a hallmark of obsessive-compulsive personality disorder. Clients often set excessively high standards for themselves and others, are preoccupied with orderliness, and may have difficulty delegating tasks.

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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 reviewing the medical record of a client who has a prescription for intermittent heat therapy for a foot injury. Which of the following findings should the nurse identify as a contraindication for heat therapy?

Correct Answer is D

Explanation

A nurse is assessing a client who has obsessive-compulsive personality disorder. Which of the following manifestations should the nurse expect?

Correct Answer is D

Explanation

A nurse is caring for a client who has just started having a seizure. Which of the following interventions should the nurse implement?

A nurse is providing teaching to a client who has a new diagnosis of type I diabetes mellitus about administering NPN insulin and regular insulin together in one injection. Which of the following instructions should the nurse include?

A nurse and an assistive personnel (AP) are assigned a group of clients on the unit. Which of the following clients should the nurse instruct the AP to report to the nurse?

A nurse is caring for a client who has a spinal cord injury. Which of the following support devices should the nurse plan to use to prevent plantar flexion contractures?

A nurse is measuring the fundal height of a client who is at 36 weeks of gestation. The client suddenly reports nausea. Which of the following actions should the nurse take?

A nurse working in a health department is conducting a health screening for a group of farmworkers. Which of the following client statements indicates a possible health risk?

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.