A nurse is assisting with the initiation of epidural analgesia for a client who is in the second stage of labor. Which of the following actions should the nurse take?

Monitor the client's vital signs every hour following the procedure.

Review the client's platelet count level prior to the procedure.

Inform the client that their bladder should be full before the procedure.

Obtain the client's consent following the procedure.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Monitor the client's vital signs every hour following the procedure: Vital signs, especially blood pressure, should be monitored more frequently—usually every 5 to 15 minutes immediately after epidural initiation—to assess for hypotension, a common complication.

B. Review the client's platelet count level prior to the procedure: A low platelet count increases the risk of epidural hematoma during needle insertion. Reviewing coagulation status is essential to ensure it's safe to proceed with epidural placement.

C. Inform the client that their bladder should be full before the procedure: The bladder should be emptied, not full, prior to the procedure. A full bladder increases discomfort, impairs fetal descent, and may lead to urinary retention after the epidural is placed.

D. Obtain the client's consent following the procedure: Informed consent must be obtained before any invasive procedure, including epidural anesthesia. Performing the procedure without prior consent violates patient autonomy and legal standards.

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Correct Answer is A

Explanation

Rationale:

A. I should visually monitor the client continuously when in mechanical restraints: Continuous visual monitoring is required when a client is placed in mechanical restraints to ensure safety, assess physical and psychological well-being, and promptly address any complications such as impaired circulation or distress.

B. I should ask the provider to write a prescription for mechanical restraints as needed: PRN (as needed) prescriptions for restraints are not permitted. A new, time-limited order must be obtained for each specific episode to ensure proper use and prevent misuse or overuse of restraints.

C. I should expect the provider to evaluate the client within 4 hours of restraint application: For adult clients, the provider must evaluate the client face-to-face within 1 hour of applying restraints, not 4 hours. This rule ensures timely review of the necessity and appropriateness of the intervention.

D. I should assess the client's skin integrity every 8 hours while in mechanical restraints: Skin integrity should be assessed at least every 2 hours or more frequently depending on facility policy. Waiting 8 hours increases the risk of skin breakdown and other complications.

A. Monitor for elevated temperature B. Assess for urinary retention C. Assist the client with ambulation D. Inform the Client to expect drowsiness E. Encourage the cue to turn from side to side

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

Rationale:

Monitor for elevated temperature: Epidural anesthesia can mask symptoms of infection such as chorioamnionitis. Monitoring temperature helps detect early signs of infection or epidural-related complications.
Assess for urinary retention: Epidural anesthesia often causes loss of bladder sensation, increasing the risk for urinary retention. Regular assessments are needed to determine when catheterization is required.
Assist the client with ambulation: After epidural anesthesia, lower limb motor function may be impaired. Ambulation is unsafe due to the risk of falls and injury; bedrest is generally advised until full motor function returns.
Inform the client to expect drowsiness: Drowsiness is not a typical side effect of epidural anesthesia; it may indicate systemic absorption or another issue. Encouraging drowsiness may mask concerning symptoms that need prompt evaluation.
Encourage the client to turn from side to side: Repositioning helps maintain optimal uteroplacental perfusion and prevents hypotension caused by vena cava compression from aortocaval syndrome.

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A nurse is assisting with the initiation of epidural analgesia for a client who is in the second stage of labor. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a mental health unit is teaching a newly licensed nurse about the use of mechanical restraints. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is caring for a client in active labor. Exhibits The nurse is assuming care for the client at 0305. For each nursing action, click to specify if the nursing action is essential or contraindicated for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

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