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 C
Explanation
The correct answer is choice C. Ask what the patient ate and drank within the last day or two.This is because the nurse needs to assess the patient’s current nutritional status and eating habits before providing any education or advice.The nurse can then tailor the counseling to the patient’s specific needs and preferences.
Choice A is wrong because it is not the first action that the nurse should take.While it is important to explain the importance of adequate nutrition for the patient’s own growth and development, this should be done after assessing the patient’s current situation.
Choice B is wrong because it is not the first action that the nurse should take.While it is important to explain the relationship between the patient’s eating habits and fetal development, this should be done after assessing the patient’s current situation.
Choice D is wrong because it is not the first action that the nurse should take.While it is important to discuss with the patient the basic nutritional requirements of pregnancy, this should be done after assessing the patient’s current situation.
The normal ranges for nutritional intake during pregnancy vary depending on the age, weight, activity level, and health status of the patient.
However, some general guidelines are:
• Increase calorie intake by about 300 calories per day
• Increase protein intake by about 25 grams per day
• Increase calcium intake by about 1000 milligrams per day
• Increase iron intake by about 27 milligrams per day
• Increase folic acid intake by about 600 micrograms per day
• Increase fluid intake by about 8 to 10 cups per day
Correct Answer is C
Explanation
The correct answer is choice C and explain why.Nipple stimulation can cause uterine contractions and increase the risk of preterm labor, especially in a twin gestation.
The client should avoid nipple stimulation until term or as instructed by the provider.
Choice A is wrong because cocoa butter can help moisturize the skin and prevent itching and dryness.
It does not prevent stretch marks, but it is not harmful.
Choice B is wrong because resting several times a day, lying on the left side, can improve blood flow to the uterus and reduce swelling in the lower extremities.
It is a recommended self-care measure for the third trimester of pregnancy.
Choice D is wrong because drinking at least eight glasses of water a day can prevent dehydration, constipation, and urinary tract infections.
It can also help regulate body temperature and amniotic fluid volume.
Normal ranges for twin gestation are similar to singleton gestation, except for fundal height and weight gain.
The fundal height should be measured in centimeters from the pubic symphysis to the top of the uterus.
It should be approximately equal to the number of weeks of gestation plus or minus 4 cm until 32 weeks, then it may plateau or decrease slightly.
The weight gain should be between 35 and 45 pounds for a normal-weight woman, 25 to 42 pounds for an overweight woman, and 15 to 25 pounds for an obese woman.
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