A nurse is caring for a client who received epidural analgesia during labor and is 4 hr postpartum. Which of the following client reports should the nurse address first?

Tingling in her legs

Abdominal cramps

Itching

Inability to void

Answer and Explanation

The Correct Answer is D

Epidural analgesia during labor can cause temporary bladder dysfunction, which may result in an inability to void. This is due to the epidural medication affecting the nerves that control the bladder. If the client is unable to void, it can lead to bladder distention, which can be uncomfortable for the client and increase the risk of infection.

Tingling in her legs, abdominal cramps, and itching are common side effects of epidural analgesia, and can be addressed after the client's inability to void is addressed. The nurse can provide the client with education on these side effects and reassurance that they are typically temporary and should resolve on their own.

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Correct Answer is C

Explanation

The priority action in this scenario is to prevent infection. Cleansing the site with povidone-iodine can help reduce the risk of infection. Rectal temperature monitoring and administration of antibiotics may be necessary if infection is suspected, but preventing infection is the priority. Surgical closure may be necessary, but this is not an immediate concern.

A. Dizziness B. Increased urination C. Sweating D. Double vision

Correct Answer is B

Explanation

Increased urination, or polyuria, is a common clinical finding in clients with hyperglycemia. High levels of glucose in the blood can cause the kidneys to work harder to filter out the excess glucose, resulting in increased urine output.

Option A, dizziness, is a nonspecific symptom and can occur for a variety of reasons, including hypoglycemia, hyperglycemia, or dehydration.

Option C, sweating, is also a nonspecific symptom and can occur for a variety of reasons, including hypoglycemia, hyperglycemia, or anxiety.

Option D, double vision, is a symptom that can occur in severe cases of hyperglycemia or diabetic ketoacidosis. However, it is not a common or early symptom of hyperglycemia.

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A nurse is caring for a client who received epidural analgesia during labor and is 4 hr postpartum. Which of the following client reports should the nurse address first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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