A nurse is caring for a client who is in labor and has received an epidural. Which of the following actions should the nurse take?

Decrease the maintenance infusion rate of IV fluid.

Have protamine sulfate available at the bedside.

Reposition the client side-to-side each hour.

Monitor the client for hypertension

Answer and Explanation

The Correct Answer is C

A. Decrease the maintenance infusion rate of IV fluid. Epidural anesthesia can cause hypotension, so IV fluids are often used to help maintain blood pressure. Reducing the fluid rate may increase the risk of hypotensive episodes.
B. Have protamine sulfate available at the bedside. Protamine sulfate is the antidote for heparin, not relevant to epidural anesthesia. It is not required in the management of epidural-related side effects.
C. Reposition the client side-to-side each hour. Frequent repositioning helps prevent pressure injuries, promotes fetal oxygenation, and encourages effective labor progression. It also aids in the distribution of the anesthetic agent.
D. Monitor the client for hypertension. Hypotension, not hypertension, is a common adverse effect of epidural anesthesia due to vasodilation and decreased peripheral resistance. Blood pressure should be monitored closely for drops.

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Correct Answer is A

Explanation

A. "I will use a communication board to assess the client's needs." This demonstrates appropriate use of assistive tools tailored for individuals with visual impairments. Communication boards can include tactile or auditory features, allowing clients to express needs effectively without relying on vision.
B. “I will collaborate with a speech therapist about the client's plan of care." While speech therapy may be helpful in some situations, it is not directly related to communication strategies for a client with visual impairment unless there is a concurrent speech or language issue.
C. "I will use indirect lighting in the client's room." Indirect lighting can reduce glare, which may help clients with partial vision, but this action does not address communication needs or strategies specific to visual impairment.
D. “I will use a loud tone of voice when speaking with the client.” Clients with visual impairments do not necessarily have hearing impairments. Raising the voice unnecessarily can be perceived as patronizing or inappropriate unless hearing loss is also present.

A. "Morphine 3.0 mg sub q every 4 hr PRN for pain." B. "Morphine 3 mg subcutaneous every 4 hr PRN for pain." C. "Morphine 3 mg SC q 4 hr PRN for pain." D. "Morphine 3 mg SQ every 4 hr PRN for pain."

Correct Answer is B

Explanation

A. "Morphine 3.0 mg sub q every 4 hr PRN for pain." Including a trailing zero (3.0 mg) is considered unsafe and is discouraged in medication documentation. It increases the risk of a tenfold overdose if the decimal is missed.
B. "Morphine 3 mg subcutaneous every 4 hr PRN for pain." This entry uses the correct dosage format without a trailing zero, the full term "subcutaneous" instead of abbreviations, and proper medical terminology. It adheres to safe documentation practices as per The Joint Commission guidelines.
C. "Morphine 3 mg SC q 4 hr PRN for pain." The abbreviation “SC” is considered unsafe and prone to misinterpretation. Also, "q" for "every" is discouraged in clinical documentation due to potential misreading and error.
D. "Morphine 3 mg SQ every 4 hr PRN for pain." The abbreviation “SQ” can be misinterpreted or mistaken for “5 every” or other terms. Safe practice requires spelling out “subcutaneous” to prevent errors in medication administration.

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A nurse is caring for a client who is in labor and has received an epidural. Which of the following actions should the nurse take?

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