A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?
Place the client in a supine position for 30 min following the first dose of anesthetic solution.
Administer 1.000 mL of dextrose 5% in water prior to the first dose of anesthetic solution.
Monitor the client's blood pressure every minute following the first dose of anesthetic solution.
Ensure the client has been NPO 4 hr prior to the treatment of the epidural and the first dose of anesthetic solution.
The Correct Answer is C
Choice A Reason:
Placing the client in a supine position for 30 minutes following the first dose of anesthetic solution is not a standard recommendation. The positioning during epidural placement is typically a seated or side-lying position.
Choice B Reason:
Administering 1,000 mL of dextrose 5% in water prior to the first dose of anesthetic solution is not a standard practice for epidural anesthesi
A. Fluids may be administered, but the type and volume depend on the patient's individual needs and the healthcare provider's orders.
Choice C Reason:
Monitoring the client's blood pressure every minute following the first dose of anesthetic solution is appropriate. Epidural anesthesia can potentially cause hypotension (low blood pressure), which is a common side effect. Therefore, close monitoring of the client's blood pressure is crucial, especially following the administration of the initial dose of the anesthetic solution. The goal is to promptly detect and manage any decrease in blood pressure to ensure the well-being of both the mother and the baby.
Choice D Reason:
Ensuring the client has been NPO (nothing by mouth) for 4 hours prior to the placement of the epidural and the first dose of anesthetic solution is not a specific requirement for epidural anesthesi
A. NPO status is more relevant to surgical procedures involving general anesthesia and is not typically a strict requirement for epidural placement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A. Cervical dilation.
A. Cervical dilation is a definitive sign of labor.
Cervical dilation is the opening of the cervix, and it is a key indicator of the active phase of labor. Measurement of cervical dilation is an essential component of assessing the progress of labor.
B. Brownish vaginal discharge may indicate various things, including the presence of old blood or mucus. While it could be a sign of impending labor, it is not a definitive confirmation of active labor.
C. Amniotic fluid in the vaginal vault could suggest rupture of membranes, but it alone does not confirm the active phase of labor.
D. Pain above the umbilicus is not a specific or conclusive sign of labor. Labor pain typically originates in the lower abdomen and pelvis.
Correct Answer is B
Explanation
Choice A Reason:
Active is incorrect. The active phase of labor typically begins when the cervix is around 4 to 6 centimeters dilated. Given that the client's cervix is already dilated to 9 cm, she has progressed beyond the active phase.
Choice B Reason:
Transition is correct. The transition phase is the final part of the first stage of labor and occurs when the cervix is dilated from 8 to 10 centimeters. In this phase, contractions are typically strong, occurring every 2 to 3 minutes, and lasting 80 to 90 seconds. The sensation of increasing rectal pressure is common during the transition phase as the baby's head descends further into the birth canal. The advanced cervical dilation to 9 cm also indicates that the client is in the transition phase, preparing for the second stage of labor.
Choice C Reason:
Latent is incorrect. The latent phase is the early part of the first stage of labor, characterized by cervical dilation from 0 to 3 or 4 centimeters. The client's cervix is already dilated to 9 cm, indicating that she has progressed well beyond the latent phase.
Choice D Reason:
Descent is incorrect. The descent phase is generally associated with the second stage of labor, during which the baby moves through the birth canal. The information provided primarily relates to the first stage of labor, specifically the transition phase, as indicated by the cervical dilation of 9 cm.
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