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.

Encourage the client to turn from side to side.

Assist the client with ambulation.

Assess for urinary retention.

Inform the client to expect drowsiness.

Monitor for elevated temperature.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Rationale:

• Encourage the client to turn from side to side: Epidural anesthesia can cause hypotension and decreased uteroplacental perfusion due to sympathetic blockade. Frequent position changes help promote venous return, enhance circulation, and optimize fetal oxygenation during active labor.

• Assist the client with ambulation: Epidural anesthesia causes motor and sensory block in the lower extremities. The client will likely have reduced strength and sensation in her legs, making walking extremely dangerous due to the high risk of falls.

• Assess for urinary retention: Epidural anesthesia reduces bladder sensation and the urge to void, increasing the risk of urinary retention. A distended bladder can interfere with fetal descent and labor progress, making ongoing assessment necessary.

• Inform the client to expect drowsiness: Epidurals are local/regional anesthetics, not systemic sedatives. While the client may feel relaxed because the pain has subsided, drowsiness is not an expected side effect of an epidural. If a patient becomes drowsy or lethargic, it could indicate a complication like systemic toxicity or a profound drop in blood pressure.

• Monitor for elevated temperature: Epidural anesthesia is associated with an increased risk of maternal fever. Ongoing temperature monitoring helps identify infection or epidural-related hyperthermia early to protect both the client and fetus.

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Correct Answer is C

Explanation

A. Hypertension: Hypertension is not a typical complication of amniocentesis. While it may occur in pregnancy for other reasons, it is not directly related to this procedure and does not require specific post-procedure monitoring in this context.

B. Vomiting: Vomiting is not a common complication following amniocentesis. Nausea or discomfort may occur, but persistent vomiting is not expected and would likely be unrelated to the procedure itself.

C. Contractions: Uterine contractions are a potential complication after amniocentesis, especially in the third trimester. The nurse should monitor for signs of preterm labor, including contractions, cramping, or changes in fetal movement, to intervene promptly if needed.

D. Epigastric pain: Epigastric pain is not commonly associated with amniocentesis. It may indicate other conditions, such as preeclampsia or gastrointestinal issues, but it is not a typical post-procedure complication.

A. Ondansetron B. Guaifenesin C. Amoxicillin D. Methylprednisolone

Correct Answer is D

Explanation

A. Ondansetron: Ondansetron is an antiemetic that works by blocking serotonin receptors in the chemoreceptor trigger zone. It does not significantly affect glucose metabolism and is not associated with hyperglycemia.

B. Guaifenesin: Guaifenesin is an expectorant that thins respiratory secretions to aid clearance. It has no known effect on blood glucose levels or carbohydrate metabolism.

C. Amoxicillin: Amoxicillin is a broad-spectrum penicillin antibiotic. While it treats bacterial infections, it does not typically alter glucose metabolism or cause hyperglycemia as an adverse effect.

D. Methylprednisolone: Methylprednisolone is a corticosteroid that increases gluconeogenesis, decreases peripheral glucose uptake, and antagonizes insulin action. These mechanisms can lead to hyperglycemia, making it the likely cause of the observed increase in the child’s blood glucose.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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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.