The nurse continues to care for the client.

Exhibits

For each assessment finding, click to specify if the finding is consistent with psychosis or mania. Each finding may support more than one diagnosis.

Rationale:

A. Monitor the client for hypertension: Epidural anesthesia commonly causes hypotension due to sympathetic nervous system blockade, not hypertension. Monitoring for hypotension is more appropriate.

B. Have protamine sulfate available at the bedside: Protamine sulfate is the antidote for heparin, not epidural anesthesia. It has no relevance in managing epidural-related effects during labor.

C. Reposition the client side-to-side each hour: Changing positions frequently helps promote venous return, enhance placental perfusion, and reduce the risk of pressure injuries and aortocaval compression from a supine position.

D. Decrease the maintenance infusion rate of IV fluid: IV fluids are typically increased before and during epidural anesthesia to prevent or manage hypotension, not decreased. Reducing the rate could worsen hypotension.

Rationale:

A. “Use an electric razor when shaving while taking this medication.” Warfarin increases bleeding risk by inhibiting vitamin K–dependent clotting factors. Using an electric razor reduces the chance of cuts and bleeding during shaving, making this a critical safety teaching point.

B. “This medication can cause back pain” Back pain is not a common or expected side effect of warfarin. If a client on warfarin experiences unexplained back pain, it should be evaluated as it could indicate internal bleeding, but it is not typical enough to be part of routine teaching.

C. "Take the last dose of the day 1 hour before bedtime” Warfarin is usually taken once daily, preferably at the same time, but timing in relation to bedtime is not required. The key is consistency and regular INR monitoring to guide dosing.

D. “Avoid taking the medication with milk products” Unlike some antibiotics, warfarin’s absorption is not significantly affected by dairy. Dietary consistency with vitamin K is more important than avoiding milk, and milk products are not contraindicated.