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 C

Explanation

Rationale:

A. "Manually expressing my milk will decrease my milk supply": Milk supply is maintained by frequent emptying of the breast. Manual expression, like breastfeeding or pumping, actually stimulates continued milk production through the supply-and-demand mechanism.

B. "After 5 to 10 minutes when the breasts emptied, my baby should be removed from the breast”: Infants should not be removed from the breast based on time alone. Breastfeeding duration varies, and babies should be allowed to nurse until they release the breast or show signs of fullness.

C. "The more my baby is at the breast sucking, the more milk I will produce”: Milk production is driven by infant demand. Frequent suckling stimulates prolactin release, encouraging ongoing milk synthesis and maintaining an adequate supply.

D. "My baby should always start on the same breast when feeding”: Breastfeeding should be alternated between breasts to promote equal milk production and prevent engorgement. Starting on the same breast consistently may lead to uneven milk supply.

A. Encourage physical activity prior to bedtime B. Wear clothing with zippers instead of buttons. C. Replace the carpet with hardwood floors D. Place locks at the tops of exterior doors.

Correct Answer is D

Explanation

Rationale:

A. Encourage physical activity prior to bedtime: Stimulating activity close to bedtime can increase agitation and make it harder for clients with Alzheimer’s disease to settle for sleep. Calming routines in the evening are more appropriate to reduce nighttime confusion and restlessness.

B. Wear clothing with zippers instead of buttons: Although zippers are often easier than buttons, clients with Alzheimer’s may have difficulty with any fasteners. Simple clothing with Velcro or elastic waists is typically more suitable to promote independence.

C. Replace the carpet with hardwood floors: Carpets provide traction and cushioning, which can help prevent injuries from falls. Hardwood floors may be slippery or cause confusion due to glare or unfamiliar patterns, increasing fall risk.

D. Place locks at the tops of exterior doors: Clients with Alzheimer’s are at risk for wandering. Installing locks at the tops of doors—out of the client's usual line of sight—helps prevent elopement while preserving safety in the home environment.

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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?

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