A nurse is caring for a client who is receiving an epidural for labor pain. Which of the following actions should the nurse take?
Position the client in a lithotomy position during the epidural procedure.
Monitor the client's bladder for distention.
Administer oxygen to the client at 2 L/min via face mask.
Limit turning the client during labor.
The Correct Answer is B
A. Position the client in a lithotomy position during the epidural procedure: Epidurals are typically administered with the client in a sitting position or lying on their side with the back arched (fetal position) to allow access to the lumbar spine. Lithotomy position is not used for epidural placement.
B. Monitor the client's bladder for distention: Epidural anesthesia can decrease bladder sensation and the ability to void, increasing the risk of urinary retention. Monitoring for bladder distention and assisting with catheterization if needed is an essential nursing action to prevent complications.
C. Administer oxygen to the client at 2 L/min via face mask: Oxygen is not routinely administered to clients receiving an epidural unless there is evidence of maternal hypoxia or fetal distress. Routine oxygen is not required and should be based on assessment findings.
D. Limit turning the client during labor: While care must be taken to maintain the epidural catheter, clients can still be repositioned to promote comfort and labor progression. Turning is not prohibited, but care should be taken to avoid dislodging the catheter.
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Related Questions
Correct Answer is D
Explanation
A. Slurred speech: Slurred speech is typically associated with intoxication from central nervous system depressants, such as alcohol or opioids, rather than withdrawal. During withdrawal, the client is more likely to exhibit hyperactive or restless behavior.
B. Constricted pupils: Pupillary constriction (miosis) occurs with opioid intoxication. In contrast, opioid withdrawal usually causes dilated pupils (mydriasis) due to sympathetic nervous system overactivity.
C. Sedation: Sedation is a common effect of opioid use, not withdrawal. During withdrawal, clients are generally hyperalert, restless, and may experience insomnia rather than excessive sleepiness.
D. Yawning: Yawning is a classic sign of opioid withdrawal and reflects autonomic nervous system activation. It is often accompanied by lacrimation, rhinorrhea, sweating, and other early withdrawal symptoms.
Correct Answer is C
Explanation
A. Advise the family that a spiritual advisor will explain what life-sustaining measures are: While spiritual advisors can provide support, the nurse should focus on ensuring the client understands their rights and options rather than delegating decision-making explanations to family or advisors. The client’s autonomy is the priority.
B. Intervene if the client makes a health care decision the nurse does not agree with: The nurse must respect the client’s autonomy and decisions regarding their care, even if they personally disagree. Intervening based on personal beliefs violates ethical and legal principles of patient rights.
C. Ensure the client has identified a health care surrogate: Helping the client designate a health care surrogate ensures that someone is authorized to make decisions if the client becomes incapacitated. This is a critical step in advance care planning and aligns with legal and ethical standards.
D. Inform the client that once advance directives have been agreed upon, no changes can be implemented: Advance directives can be updated or revoked at any time while the client is competent. Providing inaccurate information could limit the client’s rights and autonomy, so the nurse should clarify that changes are always possible.
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