A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take?

Administer a 500 mL bolus of 5% dextrose in water prior to the epidural administration.

Inform the client that the anesthetic effect will last for approximately 6 hours.

Obtain a 30 min electronic fetal monitoring (EFM) strip and prepare to give a bolus of Lactated Ringers solution prior to the epidural administration.

Have the client stand very still at the bedside with her arms at her side.

Answer and Explanation

The Correct Answer is C

A: Administering a 500 mL bolus of 5% dextrose in water is not necessary before the epidural administration, and it may not be recommended in active labor as it can increase the risk of fluid overload.

B: The duration of the anesthetic effect of the epidural can vary depending on the medication used, and it is not the nurse's priority during the preparation process.

C: Prior to administering epidural analgesia, the nurse should obtain a 30minute electronic fetal monitoring (EFM) strip to assess the fetal heart rate and monitor for any signs of fetal distress during the procedure.

D: Having the client stand very still with her arms at her side is not practical or necessary for epidural administration and could be uncomfortable for the client during labor.

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Correct Answer is B

Explanation

Choice A: At 7 cm dilation, the client is in active labor, and assisting her into a more comfortable position may not be appropriate at this stage. It is essential to observe for signs of impending birth and assess the progress of labor.

Choice B: Feeling the urge to push may indicate that the baby is descending and the cervix is fully dilated. The nurse should immediately observe the perineum for signs of crowning (when the baby's head starts to appear at the vaginal opening) to prepare for delivery.

Choice C: If the client is feeling the urge to push and the cervix is fully dilated, panting or blowing through contractions will not be effective. It is important to allow the client to follow her body's natural urges to push.

Choice D: While emptying the bladder is generally recommended during labor to provide more room for the baby to descend, the client's current urge to push suggests that the baby is likely in a lower position, and it might not be safe or feasible to move the client to the bathroom.

A. Maintain the client in the lithotomy position. B. Encourage the client to empty her bladder every 2 hr. C. Remind the client to bear down with each contraction. D. Perform vaginal examinations frequently,

Correct Answer is B

Explanation

A. Maintain the client in the lithotomy position: The lithotomy position is not typically

maintained during the active phase of labor. It is used during the pushing stage (second stage) of labor.
B. Encourage the client to empty her bladder every 2 hr: A full bladder can impede fetal descent and progress during labor, so encouraging the client to empty her bladder regularly is essential.
C. Remind the client to bear down with each contraction: Bearing down during the active phase of labor is not appropriate, as it may lead to premature pushing and cervical swelling.
D. Perform vaginal examinations frequently: Frequent vaginal examinations can increase the risk of infection and should be minimized during labor.

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A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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