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 A
Explanation
A. Tachycardia: Amphetamines are central nervous system stimulants that increase sympathetic nervous system activity. Tachycardia is a common manifestation of acute toxicity, along with hypertension, hyperthermia, and agitation. Monitoring cardiovascular status is essential to prevent complications.
B. Headache: While headaches can occur with amphetamine use, they are not a primary or consistent finding in acute toxicity. More prominent signs are cardiovascular and neurological stimulation rather than mild symptoms like headache.
C. Increased appetite: Amphetamines typically suppress appetite rather than increase it. Clients experiencing acute toxicity are more likely to have decreased hunger due to stimulant effects on the hypothalamus.
D. Pupil constriction: Amphetamines usually cause mydriasis (pupil dilation) due to sympathetic stimulation. Pupil constriction is more characteristic of opioid toxicity rather than amphetamine toxicity.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.