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 D
Explanation
A. Unilateral lower leg pain:
Unilateral lower leg pain can be a symptom of deep vein thrombosis (DVT), which is a serious condition. It requires further assessment and intervention.
B. Soft, spongy fundus:
A soft, spongy fundus is not a normal finding 12 hours postpartum. The fundus should be firm and well-contracted. A soft fundus could indicate uterine atony, a potential cause of postpartum hemorrhage.
C. Saturating two perineal pads per hour:
Saturating two perineal pads per hour is not a normal finding and may indicate excessive bleeding, which is concerning for postpartum hemorrhage. This requires immediate attention.
D. Pulse rate of 56 beats/minute:
A pulse rate of 56 beats per minute can be within the normal range, especially if the client is at rest. However, it's essential to consider the overall clinical picture and whether there are any signs of distress or symptoms associated with a low pulse rate.
Correct Answer is ["12"]
Explanation
To solve this problem, the nurse needs to convert the units of oxytocin from units to milliunits.
One unit of oxytocin is equal to 1000 milliunits, so 10 units of oxytocin is equal to 10,000 milliunits.
- The concentration of oxytocin in the solution is 10,000 milliunits per 1000 mL, or 10 milliunits per mL.
- To deliver 2 milliunits per minute, the nurse needs to infuse 0.2 mL per minute of the solution.
- To convert from mL per minute to mL per hour, the nurse needs to multiply by 60 minutes per hour.
- Therefore, the nurse should program the infusion pump to deliver 0.2 x 60 = 12 mL per hour of the solution.
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