The nurse is caring for a postpartal client who is exhibiting symptoms of a spinal headache 24 hours following delivery of a normal newborn. Prior to the anesthesiologist's arrival on the unit, which action should the nurse perform?

Cleanse the spinal injection site

Apply an abdominal binder

Insert an indwelling Foley catheter

Place procedure equipment at bedside

Answer and Explanation

The Correct Answer is D

A. Cleanse the spinal injection site:
Cleansing the spinal injection site is a routine part of maintaining proper hygiene during and after the administration of spinal anesthesia. However, if the client is experiencing symptoms of a spinal headache, the priority is to prepare for potential interventions by having the necessary equipment ready rather than focusing on the site itself.

B. Apply an abdominal binder:
Applying an abdominal binder is not directly related to addressing a spinal headache. Abdominal binders are typically used for providing support to the abdominal muscles after childbirth or surgery. It wouldn't be the primary intervention for a spinal headache.

C. Insert an indwelling Foley catheter:
Inserting an indwelling Foley catheter is not a direct intervention for addressing a spinal headache. Spinal headaches are related to cerebrospinal fluid leakage and positioning. While managing the patient's overall care is important, it may not be the immediate priority in this context.

D. Place procedure equipment at bedside:
This is the most appropriate action in the context of a postpartal client exhibiting symptoms of a spinal headache. Having the necessary procedure equipment, such as materials for a blood patch, ready at the bedside ensures preparedness for potential interventions by the anesthesiologist.

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Correct Answer is C

Explanation

A. Hemoglobin A1C: Hemoglobin A1C is a test that reflects the average blood sugar levels over the past two to three months. It is not typically used for diagnosing gestational diabetes.

B. Postprandial blood glucose test: This test measures blood sugar levels after meals. While it can provide information about how the body processes glucose after eating, it's not the primary test for diagnosing gestational diabetes.

C. Fasting blood glucose: This test measures blood sugar levels after a period of fasting. It is a standard test used to diagnose gestational diabetes.

D. Oral glucose tolerance test (OGTT): This test involves fasting overnight and then drinking a glucose solution. Blood sugar levels are tested at intervals afterward. The OGTT is a common diagnostic test for gestational diabetes.

A. Placenta accreta B. Hard, painful uterine afterpains. C. Postpartum psychosis. D. Disseminated intravascular coagulation

Correct Answer is D

Explanation

A. Placenta accreta: Placenta accreta is a condition where the placenta attaches too deeply into the uterine wall. While this can be a concern, the client in this scenario has already given birth, so this may not be the highest priority at this moment.

B. Hard, painful uterine afterpains: Afterpains are common in the postpartum period, especially in women who have given birth to multiples. While they can be uncomfortable, they are generally expected and not considered a severe complication.

C. Postpartum psychosis: Postpartum psychosis is a serious mental health condition that can occur after childbirth. It is characterized by symptoms such as hallucinations, delusions, and severe mood disturbances. While it is a serious concern, it might not be the immediate priority in a client who has had a severe postpartum hemorrhage.

D. Disseminated intravascular coagulation (DIC): This is a life-threatening condition where there is widespread activation of clotting factors, leading to excessive blood clotting followed by bleeding. Given the history of severe postpartum hemorrhage, DIC is a significant concern, and prompt assessment and intervention are crucial.

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The nurse is caring for a postpartal client who is exhibiting symptoms of a spinal headache 24 hours following delivery of a normal newborn. Prior to the anesthesiologist's arrival on the unit, which action should the nurse perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is 24-weeks gestation and reports increased thirst and urination. Which diagnostic test result should the nurse report to the healthcare provider?

Correct Answer is C

Explanation

A 25-year-old client who had a severe postpartum hemorrhage following the vaginal birth of twins is transferred to the postpartum unit. The nurse knows that assessment for what complication has the highest priority for this client?

Correct Answer is D

Explanation

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