A nurse is assisting with the care of a client who is receiving epidural anesthesia for pain management during labor. Which of the following actions should the nurse take?
Remind the client to void every 4 hr.
Encourage the client to alternate from side to side every 2 hr.
Raise the four side rails on the client's bed.
Monitor the client's blood pressure.
The Correct Answer is D
Choice A reason:
The nurse should not remind the client to void every 4 hours because epidural anesthesia can cause temporary loss of bladder sensation, making it difficult for the client to know when to void. Instead, the nurse should use a bladder scanner to assess for urinary retention and encourage the client to void regularly.
Choice B reason:
Encouraging the client to alternate from side to side every 2 hours is not directly related to the administration of epidural anesthesia. This action is commonly advised for clients who are on bed rest to prevent pressure ulcers and promote circulation. However, it is not specifically necessary for the client receiving epidural anesthesia for pain management during labor.
Choice C reason:
Raising the four side rails on the client's bed is not necessary in this situation. The use of side rails should be based on the client's mobility and risk assessment for falls. If the client is receiving epidural anesthesia, they may experience reduced mobility, but the decision to use side rails should be made on an individual basis, not solely based on the anesthesia.
Choice D reason:
Monitoring the client's blood pressure is a crucial action when a client is receiving epidural anesthesia. Epidural anesthesia can cause a drop in blood pressure, leading to hypotension. By regularly monitoring the client's blood pressure, the nurse can detect any significant changes and take appropriate actions to maintain hemodynamic stability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Adolescents tend to believe their own actions might have caused their terminal illness. Choice A reason:
This statement reflects a common developmental focus for adolescents, who are often navigating issues related to identity and self-image. While they are aware of their illness, many may prioritize concerns about how they look and how they are perceived by others. This can be a significant aspect of their experience during a terminal illness.
Choice B reason:
Many adolescents imagine death as a type of monster. Although this statement acknowledges a common perception of death among some adolescents, it is not the best choice for reinforcing teaching about the perception of death in the context of a terminal illness. The focus should be on more concrete and realistic aspects of death and its implications.
Choice C reason:
This statement does reflect a valid concern but may not be as prevalent as the concern with appearance in this age group. Many adolescents, especially in a terminal situation, may focus on more immediate concerns, such as how they are perceived.
Choice D reason:
Many adolescents don't understand that death is permanent. While this statement may be true for some adolescents who are still developing a full comprehension of death, it is not the most suitable choice for this scenario. In the context of a terminal illness, it is essential to acknowledge that the adolescent likely has a clear understanding of the finality of death.
Correct Answer is D
Explanation
Choice A reason:
The client stating, "This test is to check if my baby has diabetes,” indicates a misunderstanding of the purpose of the 1-hr glucose tolerance test (GTT). The test is performed to screen for gestational diabetes in the mother, not to check the baby's diabetes status. Rationale: Gestational diabetes is a condition where high blood sugar levels develop during pregnancy, and it can affect both the mother and the baby's health.
Choice B reason:
The client mentioning, "If the result is higher than normal, I will need to be on insulin the rest of my life,” demonstrates a misconception about the implications of the 1-hr GTT. The 1-hr GTT is a preliminary screening test, and if the results are higher than normal, it indicates the need for further evaluation, but it does not immediately mean a lifetime dependence on insulin. Rationale: Insulin therapy may be required for managing gestational diabetes in some cases, but not necessarily for the rest of the mother's life.
Choice C reason:
The client saying, "If I forget and eat before the test, then I won't be able to have the test done,” indicates a misunderstanding of the test procedure. The 1-hr GTT requires fasting before the test, typically for 8 to 14 hours, to get accurate results. However, if the client mistakenly eats before the test, it doesn't mean they cannot have the test done at all; they may need to reschedule it after an appropriate fasting period. Rationale: Fasting is crucial for accurate glucose level measurement during the test.
Choice D reason:
The client stating, "If the results are high, then I need another test to see if I have gestational diabetes,” demonstrates a correct understanding of the 1-hr GTT. If the initial screening test shows elevated glucose levels, further testing, such as the 3-hour glucose tolerance test (GTT), is required to confirm the diagnosis of gestational diabetes. Rationale: The 3-hour GTT is a more comprehensive diagnostic test used to confirm or rule out gestational diabetes.
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