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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["450"]
Explanation
- To calculate the infusion rate, use the formula:
(mL of solution / grams of drug) x (grams ordered / minutes to infuse) x 60
- In this case, the formula becomes: (500 mL / 20 g) x (6 g / 20 min) x 60
- Simplify and solve: (25 mL / g) x (0.3 g / min) x 60
- The answer is 450 mL/hour
- The nurse should set the infusion pump at 450 mL/hour
Correct Answer is C
Explanation
Calcium:
Calcium is essential for the development of fetal bones and teeth, but it is not specifically linked to preventing neural tube defects like anencephaly.
Iron:
Iron is crucial for preventing anemia in pregnancy, supporting increased blood volume. However, it is not directly associated with preventing neural tube defects.
Folic acid:
Folic acid is vital for preventing neural tube defects, including anencephaly. It's recommended for women of childbearing age and especially during the early stages of pregnancy.
Vitamin D:
Vitamin D is important for bone health, but its primary function is not directly related to preventing neural tube defects like anencephaly.
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