A nurse is caring for a client who received epidural analgesia during labor and is 4 hr postpartum. Which of the following client reports should the nurse address first?
Tingling in her legs
Abdominal cramps
Itching
Inability to void
The Correct Answer is D
Epidural analgesia during labor can cause temporary bladder dysfunction, which may result in an inability to void. This is due to the epidural medication affecting the nerves that control the bladder. If the client is unable to void, it can lead to bladder distention, which can be uncomfortable for the client and increase the risk of infection.
Tingling in her legs, abdominal cramps, and itching are common side effects of epidural analgesia, and can be addressed after the client's inability to void is addressed. The nurse can provide the client with education on these side effects and reassurance that they are typically temporary and should resolve on their own.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The newborn who is 10 hr old and has new onset tachypnea should be assessed first as this could indicate a respiratory distress, which requires immediate intervention. The other options are concerning but not as urgent as respiratory distress.
A newborn with a short frenulum and difficulty breastfeeding can be assessed after the respiratory distress is addressed.
A newborn who is 24 hr old and has not had a meconium stool should be assessed for bowel sounds and abdominal distension, but it is not as urgent as respiratory distress. A newborn who is 30 hr old and has blood-tinged discharge in her diaper can be assessed after the respiratory distress is addressed. The blood-tinged discharge could be due to the infant's mother passing her own vaginal blood to the infant or a minor vaginal laceration during delivery.
Correct Answer is C
Explanation
Identification bands are an important safety measure to ensure that the newborn is properly identified and matched with the correct mother. Applying identification bands to the newborn and mother is a standard practice in all healthcare settings and is typically done immediately following delivery.
While obtaining the newborn's weight, administering IM vitamin K, and applying prophylactic eye ointment are also important interventions for a newborn, they should be done after the identification bands are applied. The order of priority for these interventions may vary depending on the healthcare facility's policies and procedures, but ensuring proper identification of the newborn is always the first step to ensure patient safety.
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