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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. After notifying the provider, the nurse should massage the client’s fundus. This action helps to contract the uterus and reduce bleeding, which is crucial in managing hypovolemic shock due to postpartum hemorrhage.

B. Insert an indwelling urinary catheter: This action is important for monitoring urine output, which is a key indicator of renal perfusion and overall fluid status. However, it is not the immediate priority when managing hypovolemic shock due to postpartum hemorrhage.

C. Administer oxygen at 10 L/min: Providing oxygen is crucial to ensure adequate tissue oxygenation, especially in a shock state. While important, it comes after addressing the source of bleeding, which is the primary cause of the hypovolemic shock.

D. Elevate the client’s right hip: This action helps to prevent uterine displacement and improve venous return, which can be beneficial. However, it is not the first step in managing hypovolemic shock due to postpartum hemorrhage.

A. Tell the client to follow up with a dermatologist B. Explain to the client this is an expected occurrence. C. instruct the client to increase her intake of vitamin D D. Inform the client she might have an allergy to her skin care products

Correct Answer is B

Explanation

The correct answer is B. Explain to the client this is an expected occurrence.

A. Tell the client to follow up with a dermatologist: While it's always good to encourage clients to seek professional advice if they have concerns, in the context of melasma during pregnancy, it is generally a normal physiological change. A dermatologist may not be needed specifically for this condition unless there are other unusual symptoms.

B. Explain to the client this is an expected occurrence: This is the correct action. It's important for the nurse to reassure the client that blotchy hyperpigmentation on the forehead is a common and expected change during pregnancy. Providing education and support can help alleviate the client's concerns.

C. Instruct the client to increase her intake of vitamin D: Blotchy hyperpigmentation is not typically addressed by increasing vitamin D intake. While adequate nutrition is important during pregnancy, this specific concern is related more to hormonal changes than nutritional deficiencies.

D. Inform the client she might have an allergy to her skin care products: Melasma is primarily related to hormonal changes in pregnancy rather than an allergic reaction to skin care products. While assessing for allergies is essential in certain situations, it may not be the primary concern in this case.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

A nurse is caring for a client who is at 22 weeks of gestation and reports concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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