After delivering a healthy baby boy with epidural anesthesia, a woman on the after-birth unit complains of a severe headache. The nurse should anticipate which actions in the patient's plan of care? (Select all that apply.)

Frequent monitoring of vital signs

Assisting with a blood patch procedure

Correct Administration of oral analgesics

Keeping the head of bed elevated at all times

Answer and Explanation

Correct Answer : A,B,C

A. Frequent monitoring of vital signs. A post-dural puncture headache (PDPH) can occur after epidural anesthesia due to leakage of cerebrospinal fluid (CSF). Monitoring vital signs, particularly blood pressure and heart rate, helps assess for hypotension, fluid balance, and overall neurological status.

B. Assisting with a blood patch procedure. An epidural blood patch is the most effective treatment for a severe post-dural puncture headache. This procedure involves injecting the patient’s own blood into the epidural space to seal the CSF leak and relieve symptoms. The nurse should prepare for the procedure and educate the patient about it.

C. Administration of oral analgesics. Oral analgesics, such as acetaminophen or ibuprofen, are used to relieve mild to moderate headache symptoms. However, they may not be fully effective for a severe PDPH and are often used as supportive therapy along with other interventions.

D. Keeping the head of bed elevated at all times. Lying flat, rather than elevating the head of the bed, is actually recommended to help reduce CSF leakage and alleviate headache symptoms. Keeping the head elevated may worsen the headache by increasing CSF pressure changes.

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Correct Answer is D

Explanation

A. Diuresis. Increased urine output is a positive sign in a postpartum woman with preeclampsia, indicating that fluid shifts are occurring and the kidneys are functioning well. Magnesium sulfate does not cause fluid retention, and diuresis is not a major concern at this time.

B. Hypotension. While magnesium sulfate can cause vasodilation, leading to a mild decrease in blood pressure, severe hypotension is not the primary concern. The main hemodynamic concern postpartum is ensuring adequate uterine tone and preventing hemorrhage.

C. Increased risk for seizures. Magnesium sulfate is given to prevent eclampsia-related seizures, and its continued administration postpartum helps reduce seizure risk. The risk of seizures decreases after delivery, but stopping the infusion too early could increase the risk, making this a secondary rather than primary concern.

D. Excessive uterine bleeding. Magnesium sulfate relaxes smooth muscle, including the uterus, which can lead to uterine atony and increased postpartum hemorrhage risk. This is a critical concern in the immediate postpartum period, as uterine atony can result in life-threatening blood loss requiring urgent intervention.

A. Tell the client to take a warm shower, rest, and call back tomorrow. B. Schedule an appointment for the client at the clinic tomorrow. C. Instruct the client to drink cranberry juice and call if she experiences a fever. D. Instruct the client to go to labor triage at the hospital for evaluation.

Correct Answer is D

Explanation

A. Tell the client to take a warm shower, rest, and call back tomorrow. While rest and hydration can sometimes help with mild discomfort, this client’s symptoms—pelvic pressure, low back pain, abdominal pain, and increased vaginal discharge—are concerning for preterm labor and require immediate evaluation. Delaying care could increase the risk of preterm birth.

B. Schedule an appointment for the client at the clinic tomorrow. Waiting until the next day is not appropriate, as preterm labor is an urgent condition that needs immediate assessment to prevent premature birth. Prompt intervention may allow for tocolytic therapy or steroid administration to improve fetal lung maturity if preterm birth is imminent.

C. Instruct the client to drink cranberry juice and call if she experiences a fever. Cranberry juice is sometimes used to prevent urinary tract infections (UTIs), but this client’s symptoms are more indicative of preterm labor rather than an infection. Fever is not a defining symptom of preterm labor, and delaying care could result in complications.

D. Instruct the client to go to labor triage at the hospital for evaluation. This is the best response because the symptoms suggest possible preterm labor. Evaluation in the hospital can include cervical checks, fetal monitoring, and tests such as fetal fibronectin (fFN) to assess the risk of preterm birth. Immediate intervention can help delay labor and improve neonatal outcomes.

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After delivering a healthy baby boy with epidural anesthesia, a woman on the after-birth unit complains of a severe headache. The nurse should anticipate which actions in the patient's plan of care? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A woman with preeclampsia gave birth vaginally 1 hour ago. She is still receiving a magnesium sulfate infusion at 1 gm/hr. A major concern regarding the administration of magnesium sulfate at this time would be:

Correct Answer is D

Explanation

A client who is 32 weeks pregnant calls the clinic complaining of an increase in vaginal discharge, pelvic pressure, and low back and abdominal pain. Based on this information, what action will the nurse take?

Correct Answer is D

Explanation

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