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 C
Explanation
Birth weight has doubled.
Choice A reason:
The nurse should not expect a positive Babinski sign in a 4-year-old child during a well-child visit. The Babinski sign is a reflex seen in infants up to about 1 year of age and disappears as the nervous system matures. Its presence in a 4-year-old would be abnormal and may indicate neurological issues.
Choice B reason:
The nurse should not expect birth height to double in a 4-year-old child during a well-child visit. While children do experience significant growth in their early years, it is unlikely that birth height will have doubled by the age of 4. Doubling of birth height would be an atypical finding.
Choice C reason:
The correct choice. The nurse should expect that the child's birth weight has doubled during a well-child visit. From birth to age 4, children typically experience substantial weight gain, and doubling of birth weight is a common milestone in healthy development.
Choice D reason:
The nurse should not expect the presence of permanent teeth in a 4-year-old child during a well-child visit. Permanent teeth typically begin to emerge around 6 years of age and continue to erupt over the following years. The appearance of permanent teeth at age 4 would be premature and unusual.
Correct Answer is B
Explanation
Choice A reason:
Obtaining vital signs is essential in assessing the child's overall condition, but it is not the first action the nurse should take in this situation. The priority is to address the immediate concern of difficulty breathing.
Choice B reason:
Stopping the IV infusion is the most critical action the nurse should take first. Difficulty breathing can be a sign of a severe allergic reaction, and if it is related to the IV cefuroxime, stopping the infusion will prevent further administration of the medication and possibly worsening the reaction.
Choice C reason:
Administering epinephrine IM is not the first-line action in this scenario. Epinephrine is used in severe anaphylactic reactions, but it should not be given without a proper evaluation of the situation and a clear indication for its use.
Choice D reason:
Monitoring intake and output is an important nursing intervention, but it is not the priority when the child is experiencing difficulty breathing. Addressing the respiratory distress should be the initial focus to ensure the child's safety and well-being.
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