A nurse is caring for a client who is receiving an epidural for labor pain. Which of the following actions should the nurse take?

Position the client in a lithotomy position during the epidural procedure.

Monitor the client's bladder for distention.

Administer oxygen to the client at 2 L/min via face mask.

Limit turning the client during labor.

Answer and Explanation

The Correct Answer is B

A. Position the client in a lithotomy position during the epidural procedure: Epidurals are typically administered with the client in a sitting position or lying on their side with the back arched (fetal position) to allow access to the lumbar spine. Lithotomy position is not used for epidural placement.

B. Monitor the client's bladder for distention: Epidural anesthesia can decrease bladder sensation and the ability to void, increasing the risk of urinary retention. Monitoring for bladder distention and assisting with catheterization if needed is an essential nursing action to prevent complications.

C. Administer oxygen to the client at 2 L/min via face mask: Oxygen is not routinely administered to clients receiving an epidural unless there is evidence of maternal hypoxia or fetal distress. Routine oxygen is not required and should be based on assessment findings.

D. Limit turning the client during labor: While care must be taken to maintain the epidural catheter, clients can still be repositioned to promote comfort and labor progression. Turning is not prohibited, but care should be taken to avoid dislodging the catheter.

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Correct Answer is D

Explanation

A. Dietitian: While nutrition can play a role in overall health and inflammation management, a dietitian referral is not the primary intervention for rheumatoid arthritis. Dietary counseling may be considered adjunctively but is not central to preserving joint function.

B. Case manager: A case manager helps coordinate care and resources, which may be helpful for complex cases, but referral is not specifically targeted to managing the functional impairments associated with rheumatoid arthritis.

C. Podiatrist: A podiatrist is consulted if the client develops foot or ankle complications. Routine referral is not indicated unless specific joint issues are present in the lower extremities.

D. Physical therapist: Physical therapy is essential in rheumatoid arthritis care to maintain joint mobility, reduce pain, and prevent deformities. A physical therapist develops individualized exercise programs, educates on joint protection, and supports functional independence, making this referral highly appropriate.

A. A 32-year-old client who has chlamydia B. A 50-year-old client who has Candida albicans C. A 25-year-old client who has vaginal trichomonas D. A 40-year-old client who has streptococcal pharyngitis

Correct Answer is D

Explanation

A. A 32-year-old client who has chlamydia: Chlamydia is a sexually transmitted infection that is not transmitted via airborne or droplet routes. Standard precautions are sufficient, and a private room is not required.

B. A 50-year-old client who has Candida albicans: Candida infections are generally superficial and not highly contagious. Standard precautions are adequate, so a private room is not necessary.

C. A 25-year-old client who has vaginal trichomonas: Trichomoniasis is a sexually transmitted infection and does not require isolation. Standard precautions are appropriate for this client.

D. A 40-year-old client who has streptococcal pharyngitis: Streptococcal pharyngitis is transmitted via respiratory droplets. Placing the client in a private room or with another client who has the same infection helps prevent transmission, making a private room the most appropriate assignment.

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A nurse is caring for a client who is receiving an epidural for labor pain. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has rheumatoid arthritis. Which of the following referrals should the nurse recommend?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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