A nurse is caring for a client in active labor.
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.
Assist the client with ambulation.
Monitor for elevated temperature.
Inform the client to expect drowsiness.
Assess for urinary retention.
Encourage the client to turn from side to side.
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}
Rationale for Essential Actions:
- Monitor for elevated temperature: Epidural anesthesia can increase the risk of maternal fever due to decreased peripheral heat loss. Monitoring temperature helps detect infection or epidural-related hyperthermia early.
- Assess for urinary retention:Epidural anesthesia can impair bladder sensation and motor control, making urinary retention common. Ongoing bladder assessments are crucial to prevent bladder distention and associated labor complications.
- Encourage the client to turn from side to side: Repositioning promotes fetal descent and optimal uteroplacental perfusion, and helps prevent supine hypotension by avoiding vena cava compression in laboring women.
Rationale for Contraindicated Actions:
- Assist the client with ambulation: Epidural anesthesia impairs lower extremity motor function and balance, posing a high fall risk. Bedrest is required after epidural placement unless sensation and motor function are fully restored and evaluated.
- Inform the client to expect drowsiness: Drowsiness is not a typical or expected effect of epidural anesthesia. Sedation may indicate systemic effects or complications and should not be presented as expected.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Esophagitis: Esophagitis is not a common manifestation of systemic lupus erythematosus (SLE). It is more often associated with gastroesophageal conditions or certain medications rather than autoimmune flare-ups.
B. Fever: Fever is a common finding during an acute exacerbation of SLE, reflecting the inflammatory nature of the autoimmune response and potential systemic involvement, such as joint pain or organ inflammation.
C. Diplopia: Diplopia, or double vision, is more associated with neurological conditions like multiple sclerosis rather than SLE, which more commonly affects joints, skin, and internal organs.
D. Bradykinesia: Bradykinesia is characteristic of Parkinson’s disease and other movement disorders, not typically seen in clients experiencing an SLE flare.
Correct Answer is B
Explanation
A. Insert the oral thermometer in front of the infant's tongue: Oral temperature is not recommended for infants due to the risk of injury and difficulty keeping the thermometer in place.
B. Place the tip of the thermometer under the center of the infant's axilla: The axillary route is safe and appropriate for infants. Ensuring the tip is in full contact with the skin in the center of the axilla ensures a more accurate reading.
C. Pull the pinna of the infant's ear forward before inserting the probe: For infants under 3 years, the pinna should be pulled down and back to straighten the ear canal, not forward.
D. Insert the probe 3.8 cm (1.5 in) into the infant's rectum: This depth is excessive for an infant; rectal insertion should be only about 1.3 to 2.5 cm (0.5 to 1 in) to avoid rectal trauma.
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