A nurse is caring for a primigravida whose cervix is 2 cm dilated, 75% effaced, and the fetal presenting part is at +2 station.
The patient says to the nurse, “I want an epidural now.Why won’t someone give me an epidural?” Which response is most appropriate for the nurse to make?
“Your labor may slow down if you receive an epidural now.”.
“You need to be at least eight centimeters dilated prior to receiving an epidural.”.
“You will need to be catheterized prior to receiving an epidural.”.
“Your baby needs to be at zero station before you can have an epidural.”.
The Correct Answer is A
The correct answer is choice A. “Your labor may slow down if you receive an epidural now.” An epidural is a type of regional anesthesia that blocks pain in a specific area of the body.
It can be used to reduce pain during labor and delivery.
However, an epidural can also have some side effects, such as lowering blood pressure, causing fever, and slowing down labor progress.
Therefore, it is usually recommended to wait until the cervix is at least 4 to 5 cm dilated and the contractions are strong and regular before receiving an epidural.
Choice B is wrong because there is no fixed rule about how dilated the cervix needs to be before receiving an epidural.
Some women may receive an epidural earlier or later than others, depending on their pain level, medical history, and preferences.
Choice C is wrong because catheterization is not a prerequisite for receiving an epidural.
Catheterization is the insertion of a tube into the bladder to drain urine.
It may be done after receiving an epidural because the anesthesia can affect the ability to urinate.
However, it is not required before receiving an epidural.
Choice D is wrong because the station of the baby does not determine when a woman can have an epidural.
The station of the baby refers to how far the baby has descended into the pelvis.
It is measured in relation to the ischial spines, which are bony landmarks in the pelvis.
A positive station means that the baby is below the spines, while a negative station means that the baby is above the spines.
Zero station means that the baby is at the level of the spines.
The station of the baby does not affect the administration of an epidural, as long as there are no other complications or contraindications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. Taking mineral oil each night is not recommended for pregnant women who have hemorrhoids because it can interfere with the absorption of fat-soluble vitamins and cause diarrhea, which can worsen hemorrhoids.
The patient should avoid laxatives and stool softeners unless prescribed by a health care provider.
Choice A is wrong because walking at least a mile a day can help improve blood circulation and prevent constipation, which are both beneficial for hemorrhoid management.
Choice C is wrong because including foods high in fiber in the diet can help soften stools and prevent straining, which can aggravate hemorrhoids.
Choice D is wrong because drinking one extra glass of water before breakfast each morning can help hydrate the body and prevent dehydration, which can cause hard stools and increase pressure on the anal veins.
The nurse should teach the patient other strategies for hemorrhoid management, such as applying ice packs or witch hazel pads to the affected area, using sitz baths or warm water baths, avoiding prolonged sitting or standing, and wearing cotton underwear.
The nurse should also advise the patient to report any signs of infection or bleeding to the health care provider.
Correct Answer is D
Explanation
The correct answer is choice D. If the client feels like she has butterflies in her stomach, it means her baby is moving.
This is a normal and expected change during pregnancy, especially in the second and third trimesters.The baby’s movements can be felt as flutters, kicks, or rolls.
Choice A is wrong because spotting of blood on the underwear is not a normal change during pregnancy.
It can indicate a problem such as placenta previa, placental abruption, or miscarriage.Any bleeding during pregnancy should be reported to the health care provider.
Choice B is wrong because clear fluid leaking from the vagina is not a normal change during pregnancy.
It can indicate that the membranes have ruptured and amniotic fluid is escaping.
This can lead to infection and preterm labor if not treated promptly.Any fluid leakage during pregnancy should be reported to the health care provider.
Choice C is wrong because dark patches on the face are not a sign of high blood pressure during pregnancy.
They are called melasma or chloasma and are caused by increased pigmentation due to hormonal changes.They usually fade after delivery and are not harmful.High blood pressure during pregnancy can cause symptoms such as headache, blurred vision, swelling, and protein in the urine.
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