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.

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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. "The client was intubated without complications.": While relevant to the surgical process, this detail is more critical in the operating or PACU setting and less essential for ongoing post-op care unless complications occurred.
B. "The client is a member of the board of directors.": This is not clinically relevant and violates the client’s confidentiality by sharing unnecessary personal information.
C. "There was a total of 10 sponges used during the procedure.": Sponge count is important intraoperatively, but it is not typically necessary in a hand-off unless a count discrepancy occurred.
D. "The estimated blood loss was 250 milliliters.": This is clinically relevant and necessary for postoperative monitoring. It informs the receiving nurse about potential volume loss and the need to monitor for signs of hypovolemia.

A. Providing clients with information about the benefits of exercise B. Using an electronic messaging system to remind clients when to take medications C. Helping clients understand health screenings covered by their insurance plans D. Educating clients about contraindications to specific immunizations

Correct Answer is B

Explanation

A. Providing clients with information about the benefits of exercise: This is an example of primary prevention, aimed at promoting general health and preventing illness before it occurs, not managing an existing condition like HIV.
B. Using an electronic messaging system to remind clients when to take medications: This represents tertiary prevention, which focuses on managing chronic illness to prevent complications and improve quality of life. Medication adherence helps control HIV progression and maintain health.
C. Helping clients understand health screenings covered by their insurance plans: This is a secondary prevention activity, aimed at early detection of disease through screening, rather than managing an existing diagnosis.
D. Educating clients about contraindications to specific immunizations: This aligns with primary prevention, as it relates to preventing illness through safe vaccination practices, not managing or treating an existing chronic disease.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?

Correct Answer is D

Explanation

A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention?

Correct Answer is B

Explanation

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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.