A client with an epidural cannot feel her legs. What is the priority nursing action?
Increase stimulation
Implement fall precautions
Encourage walking
Remove epidural
The Correct Answer is B
Epidural anesthesia involves the administration of local anesthetics into the extradural space to induce regional analgesia. It causes a predictable motor blockade by inhibiting nerve impulse transmission along the spinal nerve roots. Monitoring for sensory and motor deficits is a standard clinical requirement for patient safety.
A. Increase stimulation: Attempting to heighten sensory input is ineffective because the neural pathways are chemically interrupted by the anesthetic agent. Forcing sensation through vigorous stimuli does not reverse the blockade and may cause skin irritation. This action does not address the primary safety risk of impaired mobility.
B. Implement fall precautions: Loss of lower extremity sensation and motor control creates a high risk for mechanical trauma during transfers or positional changes. Ensuring the side rails are up and providing assistance with movement are necessary to maintain physical integrity. This is the highest priority when a patient’s proprioception is compromised.
C. Encourage walking: Ambulation is strictly contraindicated until the motor block has completely dissipated and the patient demonstrates adequate muscle strength. Attempting to walk while legs are numb leads to immediate falls and potential fractures. Safety protocols require a successful sensory-motor assessment prior to any weight-bearing activity.
D. Remove epidural: Temporary loss of sensation is an expected pharmacological effect of the procedure and does not necessarily warrant premature discontinuation. The nurse should monitor the level of the block rather than removing the catheter without a specific medical order. Management focuses on injury prevention until the drug is metabolized.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The second stage of labor commences once the cervix achieves full dilation and complete effacement. This physiological milestone allows the fetal head to descend into the vaginal canal without causing cervical trauma or edema. Pushing prior to this stage can lead to cervical lacerations and maternal exhaustion.
A. At 10 cm dilation: Reaching 10 cm marks the transition from the first to the second stage of labor. At this point, the cervix is no longer palpable, providing a clear path for fetal descent. This ensures that maternal expulsive efforts are directed effectively toward delivery rather than pushing against an undilated cervical rim.
B. When contractions stop: The cessation of contractions indicates uterine atony or the end of the third stage of labor, not the time to begin pushing. Effective pushing requires the mechanical force of uterine contractions to move the fetus through the birth canal. Without these involuntary cycles, expulsive efforts are largely ineffective.
C. At 8 cm dilation: Attempting to push at 8 cm, which is still part of the transition phase, can cause the cervix to become edematous and swollen. This swelling may stall progress and necessitate a cesarean section due to cephalopelvic disproportion created by the inflamed tissue. It increases risk of uterine rupture.
D. Immediately on admission: Admission often occurs during the latent or active phases of the first stage of labor when dilation is minimal. Pushing at this early stage is premature and causes maternal fatigue long before the second stage is reached. It serves no clinical purpose and can cause fetal distress.
Correct Answer is B
Explanation
A ruptured ectopic pregnancy is a surgical emergency characterized by massive intraperitoneal hemorrhage and hemorrhagic shock. As the gestational sac expands, it stretches the fallopian tube until the wall loses integrity and tears. This leads to peritoneal irritation and rapid loss of circulating blood volume.
A. Miscarriage: While an ectopic pregnancy is a non-viable pregnancy, a "miscarriage" typically refers to the loss of an intrauterine pregnancy. Miscarriage involves vaginal bleeding and cervical dilation but does not typically cause the hemodynamic collapse associated with a ruptured tube. It is a separate clinical entity.
B. Tubal rupture: The sudden onset of sharp, stabbing pelvic pain followed by signs of shock—such as hypotension and tachycardia—is pathognomonic for tubal rupture. This requires immediate laparotomy or laparoscopy to stop arterial bleeding. It is the leading cause of maternal mortality in the first trimester.
C. Infection: Pelvic inflammatory disease or sepsis can cause abdominal pain, but they are typically accompanied by fever, foul discharge, and an elevated white blood cell count. While infection can cause hypotension (septic shock), the clinical context of a known ectopic pregnancy points to hemorrhage.
D. Preterm labor: Labor occurring before 37 weeks involves rhythmic uterine contractions and cervical change. Ectopic pregnancies cannot reach the viability threshold required for preterm labor to occur. The pain of labor is different from the stabbing referred pain to the shoulder seen in rupture.
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