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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Outer posterior aspect of upper arm: This site, the deltoid muscle, is appropriate for small-volume IM injections (up to 1 mL). However, it is limited by muscle size and is not preferred for larger volume or more irritating medications.
B. Upper thigh: The vastus lateralis muscle of the anterior thigh is a common IM site, particularly in infants and young children. While suitable, it may be less preferred in adults unless other sites are contraindicated.
C. Abdomen: The abdomen is not used for intramuscular injections; it is a common site for subcutaneous injections, such as insulin or heparin. Administering an IM injection in the abdomen would risk improper absorption and injury.
D. Ventrogluteal: The ventrogluteal site is preferred for intramuscular injections in adults because it is away from major nerves and blood vessels, allows for larger volumes of medication, and has a consistent muscle mass. It minimizes the risk of complications and is considered the safest IM injection site.
Correct Answer is D
Explanation
A. Position the newborn on their abdomen after feeding: Placing a newborn on their abdomen after feeding increases the risk of aspiration and sudden infant death syndrome (SIDS). The recommended position after feeding is upright or on their back when sleeping.
B. Place the newborn on a rigid feeding schedule: Strict feeding schedules can lead to overfeeding or underfeeding, both of which can increase spit-up. Feeding on demand or according to the newborn’s hunger cues is safer and helps minimize gastrointestinal discomfort.
C. Offer the newborn a pacifier after feedings: Using a pacifier may soothe the newborn but does not reduce the incidence of spit-up. It is unrelated to gastric emptying or swallowing air during feeding.
D. Burp the newborn several times during the feeding: Frequent burping helps release swallowed air, which can decrease gastric distention and reduce spit-up. This technique is an effective intervention to minimize discomfort and regurgitation in formula-fed newborns.
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