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

Paresthesia, or abnormal sensations such as tingling or numbness, is a common symptom of multiple sclerosis (MS) due to the demyelination of nerve fibers in the central nervous system. While it can be bothersome for the client, it is not typically an immediate life-threatening condition that requires urgent reporting to the healthcare provider. Ongoing management and monitoring of symptoms are important, but paresthesia alone does not necessitate immediate medical intervention.

Choice B rationale

Tremors are another common manifestation of MS, resulting from nerve damage that affects motor pathways. Tremors can significantly impact the client's quality of life, making daily activities challenging. However, like paresthesia, tremors are not usually considered an urgent condition that needs immediate reporting. They should be managed through a comprehensive care plan involving medications and physical therapy.

Choice C rationale

Tinnitus, or ringing in the ears, can occur in individuals with MS due to demyelination affecting the auditory pathways. While tinnitus can be distressing and affect the client's hearing, it is not typically an immediate life-threatening condition. It may require evaluation and symptomatic management, but it does not require urgent reporting unless it is associated with other severe symptoms.

Choice D rationale

Fever in a client with MS could indicate an infection or other inflammatory process, which can exacerbate MS symptoms and lead to a relapse. Fever may also signal a secondary complication such as a urinary tract infection or respiratory infection, which requires prompt medical attention. The healthcare provider should be notified immediately to evaluate and manage the underlying cause of the fever.

Choice E rationale

Tachycardia, or an abnormally rapid heart rate, can be a sign of several serious conditions, including infection, dehydration, or cardiovascular problems. In clients with MS, tachycardia may also indicate an autonomic dysfunction or be a response to fever or other stressors. Immediate reporting to the healthcare provider is necessary to determine the underlying cause and initiate appropriate treatment to prevent complications.

Choice A rationale

While asking the client's family to return may provide additional support, it is not a viable long-term solution as family members may have other responsibilities and commitments. It also places undue pressure on the family.

Choice B rationale

Hiring a private nurse could be a solution, but it may not be financially feasible for all clients. It also does not address the need for a comprehensive plan for both the client and her husband.

Choice C rationale

Social services can assist in arranging respite care for the client's husband, ensuring he receives the necessary care while the client recovers. Respite care is a practical solution for temporary relief for caregivers.

Choice D rationale

A case management evaluation can help assess the client's home environment and identify any potential needs or risks. However, it does not directly address the immediate concern of providing care for the husband.