A nurse is caring for a 26-year-old gravida 2 para 1 client in the labor and delivery unit.

Exhibits

Click to indicate which interventions the nurse would include in the plan of care to support the expected outcomes of adequate epidural anesthesia on the mother and the fetus. Each column must have at least one response selected.

Choice A rationale

Placing a client with a head injury in the lateral Trendelenburg position is not recommended due to the risk of increasing intracranial pressure (ICP). This position can impede venous outflow from the brain, thereby exacerbating cerebral edema and ICP. Additionally, it can compromise the airway and lead to aspiration, especially in a client who is vomiting. Proper positioning, such as elevating the head of the bed to 30 degrees, is more appropriate to facilitate venous drainage and reduce ICP while protecting the airway. This choice is scientifically unsound and potentially harmful.

Choice B rationale

Scheduling a repeat CT scan is a critical intervention in this case. The client's condition has changed, evidenced by the onset of projectile vomiting and a dilated, non-reactive left pupil, both signs of potential increased ICP and possible brain herniation. A repeat CT scan will help identify any new or worsening intracranial pathology such as bleeding, swelling, or other changes that were not present initially. Timely imaging is essential for appropriate management and to guide further treatment decisions.

Choice C rationale

Inserting a second large bore IV catheter is vital for ensuring rapid access for fluids, medications, and possible blood products in the event of an acute deterioration. This is especially important in a neurologically unstable client. Having multiple IV access points allows for efficient administration of necessary treatments without delay, which can be crucial in managing worsening intracranial conditions and other emergent needs.

Choice D rationale

While applying artificial tear drops to the left eye might seem beneficial for preventing corneal dryness in a client who cannot blink, it does not address the acute neurological concerns indicated by the pupil changes and vomiting. This intervention is more supportive rather than urgent or diagnostic. The primary focus should be on identifying and managing the underlying cause of the client's deterioration, not on symptom management alone.

Choice E rationale

Repeating the Glasgow coma assessment is necessary to monitor any changes in the client's neurological status. Regular assessment helps track the progression or improvement of the client’s condition, guiding clinical decisions. The change in pupil response and vomiting suggests potential worsening, necessitating continuous and frequent reassessments. Prompt detection of deterioration can lead to quicker intervention and potentially better outcomes.

Choice A rationale: While psychological assessment is important, it is not the primary focus for assessing outcomes in this case. The client's physical health conditions and the impact on her daily living and functional ability are more directly relevant.

Choice B rationale: Financial security is not the primary concern in this context. The primary focus is on the client's health and ability to perform activities of daily living (ADLs), which is addressed by evaluating functional improvement.

Choice C rationale: Quality of life is a broad concept that includes many aspects such as emotional, social, and physical well-being. While it is relevant, the primary outcome measure in this context is the client's functional improvement related to her health conditions and ability to manage ADLs.

Choice D rationale: Functional improvement is the correct focus for evaluating the client's outcomes. This includes her ability to perform activities of daily living (ADLs) and manage her health conditions. The nurse should assess how well the client can maintain or improve her functional abilities with the additional care provided.