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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. Refrain from using a tether strap on the car seat for children under 1 year of age: Tether straps are generally used for forward-facing car seats to reduce forward movement in a crash. Infants under 1 year should be in rear-facing seats, where tethers are not typically applicable, but the focus should be on proper rear-facing installation rather than avoiding tethers altogether.

B. Manual shoulder belts in the front seat are acceptable for school-age children over 8 years of age: Children under 13 years should ride in the back seat whenever possible, as front-seat placement increases the risk of injury from airbags and seat belts. Using front seats is not recommended solely based on age.

C. Restrict using rear-facing car seats for children after 1 year of age: Current guidelines recommend keeping children in rear-facing seats as long as possible, typically until at least age 2 or until they reach the height and weight limits of the rear-facing seat. Restricting rear-facing use at 1 year is outdated and unsafe.

D. Booster seats with belt-positioning should be used for school-age children until 8 years of age: Booster seats help position the seat belt correctly over a child’s shoulder and lap, reducing the risk of injury in a crash. This is consistent with current safety guidelines and supports proper seat belt use until the child is tall enough and meets weight requirements for adult seat belts.

A. Observe the client's ability to keep their elbows extended when using the crutches. B. Instruct the client to lean forward when using the crutches. C. Observe the client's gait pattern when using the crutches. D. Ensure the client's weight is placed on their axilla area when using the crutches.

Correct Answer is C

Explanation

A. Observe the client's ability to keep their elbows extended when using the crutches: The elbows should be slightly flexed, not fully extended, when using crutches. Observing for elbow extension is incorrect and could indicate improper technique. Proper elbow positioning is assessed as part of gait evaluation rather than as a standalone measure.

B. Instruct the client to lean forward when using the crutches: Leaning forward places excessive pressure on the axillae and increases the risk of nerve injury. Clients should maintain an upright posture while using crutches, so this instruction is unsafe and should not be included in care planning.

C. Observe the client's gait pattern when using the crutches: Observing the gait pattern allows the nurse to assess how the client distributes weight, coordinates movements, and uses the crutches safely. This assessment is essential prior to planning care and interventions, ensuring that the client can ambulate safely and independently.

D. Ensure the client's weight is placed on their axilla area when using the crutches: Weight should be supported by the hands and arms, not the axillae, to prevent nerve damage. Ensuring proper weight distribution is part of teaching and assessment, but placing weight on the axillae is incorrect and unsafe.

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