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.

Encourage the client to turn from side to side.

Assist the client with ambulation.

Assess for urinary retention.

Inform the client to expect drowsiness.

Monitor for elevated temperature.

Answer and Explanation

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

Rationale:

• Encourage the client to turn from side to side: Epidural anesthesia can cause hypotension and decreased uteroplacental perfusion due to sympathetic blockade. Frequent position changes help promote venous return, enhance circulation, and optimize fetal oxygenation during active labor.

• Assist the client with ambulation: Epidural anesthesia causes motor and sensory block in the lower extremities. The client will likely have reduced strength and sensation in her legs, making walking extremely dangerous due to the high risk of falls.

• Assess for urinary retention: Epidural anesthesia reduces bladder sensation and the urge to void, increasing the risk of urinary retention. A distended bladder can interfere with fetal descent and labor progress, making ongoing assessment necessary.

• Inform the client to expect drowsiness: Epidurals are local/regional anesthetics, not systemic sedatives. While the client may feel relaxed because the pain has subsided, drowsiness is not an expected side effect of an epidural. If a patient becomes drowsy or lethargic, it could indicate a complication like systemic toxicity or a profound drop in blood pressure.

• Monitor for elevated temperature: Epidural anesthesia is associated with an increased risk of maternal fever. Ongoing temperature monitoring helps identify infection or epidural-related hyperthermia early to protect both the client and fetus.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Teach the client to keep the cast clean and dry: While client education is important, it is not the immediate priority. Ensuring neurovascular integrity takes precedence over teaching after cast application.

B. Palpate the pulse distal to the cast: Assessing circulation, sensation, and movement distal to the cast is the first action to identify potential complications such as compartment syndrome or impaired perfusion. Early detection of neurovascular compromise is critical to prevent tissue damage.

C. Position the casted extremity on a pillow: Elevating the extremity helps reduce edema and discomfort, but it is secondary to assessing distal circulation to ensure the extremity is receiving adequate blood flow.

D. Place an ice pack over the cast: Applying ice can decrease swelling and pain; however, neurovascular assessment must be completed first to ensure that cold therapy does not mask or worsen compromised circulation.

A. The client takes 2 short naps during the day. B. The client appears to listen to unseen others. C. The client consumes 8 oz of high-calorie fluids each hour. D. The client slept 5 hr the previous night. E. The client engages in quiet activities in their room.

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

Explanation

A. The client takes 2 short naps during the day: The ability to sleep, even in short intervals, indicates a reduction in manic hyperactivity and an improvement in the client’s overall rest and circadian regulation.

B. The client appears to listen to unseen others: Persisting auditory hallucinations indicate ongoing psychotic symptoms, reflecting no improvement in the client’s mental status.

C. The client consumes 8 oz of high-calorie fluids each hour: Increased oral intake demonstrates improved self-care, nutritional status, and ability to participate in treatment, reflecting stabilization from prior neglect of eating.

D. The client slept 5 hr the previous night: Extended nighttime sleep suggests reduction of manic agitation and improved ability to rest, an important marker of therapeutic response to lithium and environmental management.

E. The client engages in quiet activities in their room: Participation in solitary, low-stimulation activities indicates decreased impulsivity and hyperactivity, demonstrating improved focus and emotional regulation.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

The nurse is continuing to care for the client. The nurse is assessing the client. Which of the following findings indicate an improvement in the client's condition? Select all that apply.

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

Explanation

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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.