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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Increased urinary frequency: Sertraline, a selective serotonin reuptake inhibitor (SSRI), is not commonly associated with increased urinary frequency. Urinary changes are more often related to other medication classes, such as diuretics or alpha-blockers.
B. Excessive sweating: Hyperhidrosis, or excessive sweating, is a known adverse effect of SSRIs, including sertraline. It occurs due to increased serotonergic activity affecting thermoregulatory centers and can be bothersome enough to require dose adjustment or symptomatic management.
C. Metallic taste in mouth: A metallic taste is more commonly reported with certain antibiotics or chemotherapy agents rather than SSRIs like sertraline. It is not a typical adverse effect of this medication.
D. Dry cough: Dry cough is not a recognized adverse effect of sertraline. Respiratory symptoms are uncommon with SSRIs and should prompt evaluation for other causes.
Correct Answer is C
Explanation
A. Warm the formula in the microwave: Microwaving formula can create hot spots that may cause burns to the child’s gastrointestinal mucosa. The formula should be warmed using a water bath or allowed to reach room temperature for safe administration.
B. Position the child at a 10° to 20° angle after feeding: The child should be positioned at a 30° to 45° angle, at minimum, during and after feeding to reduce the risk of aspiration. A 10° to 20° incline is insufficient for maintaining safe gastric emptying and airway protection.
C. Measure the tubing from the nose to the distal port: Proper measurement from the nose to the distal port (usually ending at the stomach or duodenum) ensures correct placement of the NG tube. Accurate measurement is critical to prevent feeding into the lungs or incorrect placement that could cause complications.
D. Complete the feeding in 5 min: Rapid bolus feeding can cause abdominal distension, vomiting, or aspiration in children. NG tube feedings should be administered slowly over the recommended time frame to promote tolerance and prevent complications.
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