Scenario

A nurse is caring for a 26-year-old gravida 2 para 1 female client in the labor and delivery unit. The client delivered vaginally three years ago under epidural anesthesia. She is now in active labor and has been admitted for monitoring and pain management.

Exhibits

Click to highlight the findings that indicate the client is progressing and ready for an epidural. Select three findings which indicate that this client is ready for epidural anesthesia.

Which of the following values are within normal limits?

The nurse observes an unlicensed assistive personnel (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

Temperature: 96.9 F (36.1 C) measured via internal probe via urinary catheter.

Heart rate: 128 beats/minute, sinus tachycardia (ST). Respirations: 14 breaths/minute.

Blood pressure: 90/79 mm Hg, pulse pressure less than 40 mm Hg. Oxygen saturation: 100% on 40% fraction of inspired oxygen (FiO2). IV fluid bolus given as prescribed.

The client’s surgical dressing is clean and dry.

Ecchymosis is noted on the abdomen around the dressing.

The client has a peripheral intravenous (PIV) line in the right forearm and one in the left hand.

The client also has a right subclavian central venous catheter infusing propofol and intravenous fluids.

Heart sounds are regular.

The skin is pink.

Capillary refill is 6 seconds.

Radial pulses are equal bilaterally.

Lung sounds are clear and equal bilaterally.

The client has an indwelling urinary catheter in place.

No urine is noted.

The client has no visitors at this time.

The social worker is attempting to contact family members.

The client opens her eyes to verbal stimuli and follows verbal commands.

Based on these observations, what is the most appropriate nursing action?

The healthcare provider prescribes a 5% dextrose injection with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care?

When changing the client's dressing for a vacuum-assisted closure (VAC) wound therapy system, the nurse observes foul, purulent drainage.
Which intervention(s) should the nurse implement? Select all that apply.

A client presents to the emergency department (ED) reporting abdominal pain.

The nurse observes the client's right cheek and eye are bruised and suspects possible domestic violence.

Which approach is best for the nurse to use when interviewing the client?

The nurse recognizes that findings consistent with elder mistreatment.

A nurse is caring for a 7-year-old male client who sustained a traumatic injury to the left leg after being struck by a lawnmower while playing outside.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

A nurse is caring for a 26-year-old female client who is in active labor in the labor and delivery unit.

The client has requested epidural anesthesia, and it has been administered to manage her pain during labor. The nurse is now monitoring her condition closely.