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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Free Nursing Study Resources

Correct Answer is A

Explanation

Inspect the client's face for edema:
Elevated blood pressure during pregnancy may be a sign of preeclampsia, a condition that can involve fluid retention. Edema, particularly in the face, is one of the signs that the nurse should assess for in determining if preeclampsia is a concern.

Ascertain the frequency of headaches:
Frequent headaches can be a symptom of various conditions, including preeclampsia. Gathering information about the frequency and characteristics of headaches can provide additional data for assessing the client's overall condition.

Evaluate for history of cluster headaches:
Cluster headaches, while severe, are not typically associated with elevated blood pressure during pregnancy. This information might not be directly relevant to the client's current symptoms.

Observe and time client's contractions:
Contractions are not typically associated with nausea, vomiting, or elevated blood pressure during pregnancy. This action may not address the primary concerns presented by the client.

A. Chromosomal abnormalities B. Sex and size of the infant C. Lecithin-sphingomyelin ratio D. Fetal growth and gestational age.

Correct Answer is D

Explanation

A. Chromosomal abnormalities:

While an ultrasound can sometimes identify structural abnormalities, it's not the primary tool for detecting chromosomal abnormalities. Genetic testing or procedures like amniocentesis are more specific for this purpose.

B. Sex and size of the infant:

An ultrasound is indeed used to determine the sex of the baby and assess its size and growth.

C. Lecithin-sphingomyelin ratio:

The lecithin-sphingomyelin ratio is typically assessed in tests related to fetal lung maturity, which is not the primary purpose of a routine ultrasound.

D. Fetal growth and gestational age:

This is one of the primary purposes of a routine ultrasound during pregnancy. It helps evaluate the baby's growth and ensures it aligns with the expected gestational age.

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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

A client who is 32 weeks gestation comes to the women's health clinic and reports nausea and vomiting. On examination, the nurse notes that the client has an elevated blood pressure. Which action should the nurse implement next?

Correct Answer is A

Explanation

A primipara at 20-weeks gestation is scheduled for an ultrasound. In preparing the client for the procedure, the nurse should explain that the primary reason for conducting this diagnostic study is to obtain which information?

Correct Answer is D

Explanation

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