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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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Apply a tourniquet below the venipuncture site: The tourniquet should be applied above the venipuncture site to engorge the vein and make it more visible and easier to access.
B. Choose a vein that is palpable and straight: A vein that is palpable, straight, and firm provides the best chance of successful IV insertion and reduces the risk of complications like infiltration or phlebitis.
C. Elevate the client's arm prior to insertion: Elevating the arm can actually reduce venous filling and make vein access more difficult. Instead, the arm should be in a dependent position to promote vein distention.
D. Select a site on the client's dominant arm: The non-dominant arm is generally preferred for IV insertion to minimize interference with daily activities and reduce discomfort.

A. Initiate fundal massage. B. Apply a fetal heart rate monitor. C. Insert an indwelling urinary catheter. D. Initiate an oxytocin IV infusion.

Correct Answer is B

Explanation

A. Initiate fundal massage: Fundal massage is typically used postpartum to stimulate uterine contraction and prevent hemorrhage, not during active labor, so this is not appropriate at this stage.
B. Apply a fetal heart rate monitor: Monitoring the fetal heart rate is essential after membrane rupture to assess fetal well-being and detect signs of distress during labor, making this the priority action.
C. Insert an indwelling urinary catheter: While sometimes necessary during labor if the client cannot void, catheter insertion is not a routine first action and depends on the client’s condition and labor progress.
D. Initiate an oxytocin IV infusion: Oxytocin is used to induce or augment labor but should only be started based on the healthcare provider’s order and assessment of labor progression, not immediately after membrane rupture.

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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 is preparing to insert an IV catheter for a client. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

A nurse is caring for a client who is at 38 weeks of gestation, is in active labor and has ruptured membranes. Which of the following actions should the nurse take?

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.