A nurse is reinforcing teaching about epidural PCA with a client who is in active labor. Which of the following
statements should the nurse include?
The machine is programmed to prevent you from administering more than a safe dose
During medication administration, you will not be able to move your legs freely
This method of pain control will shorten the second stage of labor
This type of anesthesia commonly causes a postpartum headache
The Correct Answer is A
a. "The machine is programmed to prevent you from administering more than a safe dose."
When reinforcing teaching about epidural PCA (patient-controlled analgesia) with a client in active labor, it is important for the nurse to inform the client about the safety features of the machine. By explaining that the machine is programmed to prevent the client from administering more than a safe dose, the nurse reassures the client that they have control over their pain relief while minimizing the risk of overdose.
Option b, "During medication administration, you will not be able to move your legs freely," is not an accurate statement regarding epidural PCA. While epidural analgesia may cause temporary weakness or loss of sensation in the lower body, the ability to move the legs freely is not necessarily completely impaired. The degree of mobility can vary depending on the dosage and specific characteristics of the epidural.
Option c, "This method of pain control will shorten the second stage of labor," is not a valid statement. Epidural PCA is primarily used for pain relief during labor and delivery but does not directly affect the progression or duration of the second stage of labor, which involves pushing and the delivery of the baby.
Option d, "This type of anesthesia commonly causes a postpartum headache," is also incorrect. While headaches can occur as a potential side effect of epidural anesthesia, they are not specifically associated with epidural PCA. Postpartum headaches can have various causes and are not exclusively related to the use of epidural PCA.
By emphasizing the safety features of the machine and explaining that it prevents the administration of excessive doses, the nurse ensures that the client understands the appropriate use of the epidural PCA for pain control during labor.
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Related Questions
Correct Answer is C
Explanation
c. Irregular, bulging veins
Deep-vein thrombosis (DVT) is a condition characterized by the formation of a blood clot in the deep veins, commonly in the lower extremities. When assessing a client with DVT, the nurse should expect to find irregular, bulging veins in the affected extremity. This is due to the obstruction of blood flow caused by the clot, leading to distension and visible changes in the appearance of the veins.
Explanation for the other options:
a. Absent dorsal pedal pulse: Absent dorsal pedal pulse is not a characteristic finding of DVT. It may be associated with peripheral arterial disease, which is a different condition involving impaired blood flow in the arteries.
b. Shiny, hairless skin: Shiny, hairless skin is not a typical finding in the affected extremity with DVT. In fact,
the skin in the area of the clot may appear red, warm to touch, and swollen.
d. Dull, aching pain: Dull, aching pain may be present in the affected extremity with DVT. However, it is important to note that some individuals with DVT may not experience any pain or may have minimal discomfort. Therefore, the absence of pain does not rule out the possibility of DVT.
In summary, irregular, bulging veins are an expected finding in the affected extremity of a client with deep- vein thrombosis (DVT). It is important for the nurse to recognize and report these signs promptly to facilitate appropriate management and prevention of complications associated with DVT.
Correct Answer is A
Explanation
Answer: (A) Inject 20 units of air into the vial of NPH insulin.
Rationale:
A) Inject 20 units of air into the vial of NPH insulin:
Injecting air into the vial of NPH insulin is the first step to prevent creating a vacuum, which could make it difficult to withdraw the insulin later. The nurse must inject the corresponding amount of air for the dose needed, ensuring that the insulin can be withdrawn smoothly and accurately without bubbles, which could affect the dose.
B) Inject 5 units of air into the vial of regular insulin:
Injecting air into the regular insulin vial is also necessary before withdrawing the insulin, but it should be done after injecting air into the NPH vial. This sequence ensures that no NPH insulin contaminates the regular insulin vial when the nurse withdraws the doses later.
C) Withdraw 20 units of NPH insulin from the vial:
Withdrawing NPH insulin should be done after air is injected into both vials and after the regular insulin has been drawn up. This sequence prevents the mixing of the two types of insulin and ensures accurate dosing, which is crucial for maintaining the correct blood glucose levels.
D) Withdraw 5 units of regular insulin from the vial:
Withdrawing regular insulin is critical to do before the NPH insulin to prevent contamination of the regular insulin with NPH, which could alter the onset and peak times of the regular insulin. However, it should follow the steps of injecting air into both vials, starting with the NPH vial.
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