After delivering a healthy baby boy with epidural anesthesia, a woman on the after-birth unit complains of a severe headache. The nurse should anticipate which actions in the patient's plan of care? (Select all that apply.)

Frequent monitoring of vital signs

Assisting with a blood patch procedure

Correct Administration of oral analgesics

Keeping the head of bed elevated at all times

Answer and Explanation

Correct Answer : A,B,C

A. Frequent monitoring of vital signs. A post-dural puncture headache (PDPH) can occur after epidural anesthesia due to leakage of cerebrospinal fluid (CSF). Monitoring vital signs, particularly blood pressure and heart rate, helps assess for hypotension, fluid balance, and overall neurological status.

B. Assisting with a blood patch procedure. An epidural blood patch is the most effective treatment for a severe post-dural puncture headache. This procedure involves injecting the patient’s own blood into the epidural space to seal the CSF leak and relieve symptoms. The nurse should prepare for the procedure and educate the patient about it.

C. Administration of oral analgesics. Oral analgesics, such as acetaminophen or ibuprofen, are used to relieve mild to moderate headache symptoms. However, they may not be fully effective for a severe PDPH and are often used as supportive therapy along with other interventions.

D. Keeping the head of bed elevated at all times. Lying flat, rather than elevating the head of the bed, is actually recommended to help reduce CSF leakage and alleviate headache symptoms. Keeping the head elevated may worsen the headache by increasing CSF pressure changes.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Diuresis. Increased urine output is a positive sign in a postpartum woman with preeclampsia, indicating that fluid shifts are occurring and the kidneys are functioning well. Magnesium sulfate does not cause fluid retention, and diuresis is not a major concern at this time.

B. Hypotension. While magnesium sulfate can cause vasodilation, leading to a mild decrease in blood pressure, severe hypotension is not the primary concern. The main hemodynamic concern postpartum is ensuring adequate uterine tone and preventing hemorrhage.

C. Increased risk for seizures. Magnesium sulfate is given to prevent eclampsia-related seizures, and its continued administration postpartum helps reduce seizure risk. The risk of seizures decreases after delivery, but stopping the infusion too early could increase the risk, making this a secondary rather than primary concern.

D. Excessive uterine bleeding. Magnesium sulfate relaxes smooth muscle, including the uterus, which can lead to uterine atony and increased postpartum hemorrhage risk. This is a critical concern in the immediate postpartum period, as uterine atony can result in life-threatening blood loss requiring urgent intervention.

A. Weight gain of 4 pounds in a month. B. Dyspnea with walking. C. Presence of striae gravidarum. D. Patellar reflexes of +2.

Correct Answer is B

Explanation

A. Weight gain of 4 pounds in a month. A weight gain of 4 pounds in a month is within the expected range for pregnancy, especially in the third trimester. While rapid or excessive weight gain could indicate fluid retention and worsening heart failure, this amount alone is not immediately concerning.

B. Dyspnea with walking. Dyspnea on exertion in a pregnant woman with congestive heart disease is a serious concern. It may indicate pulmonary congestion, worsening heart failure, or reduced cardiac output. Any increasing shortness of breath, especially with minimal activity, should be reported immediately to prevent complications like pulmonary edema or decompensated heart failure.

C. Presence of striae gravidarum. Striae gravidarum (stretch marks) are a normal skin change in pregnancy due to rapid growth and stretching of the skin. They are not related to congestive heart disease and do not require reporting.

D. Patellar reflexes of +2. A +2 deep tendon reflex (DTR) is normal and does not indicate worsening cardiac status. Reflex abnormalities are more relevant in conditions such as preeclampsia, where hyperreflexia can signal worsening disease, but they are not a concern in heart disease.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

After delivering a healthy baby boy with epidural anesthesia, a woman on the after-birth unit complains of a severe headache. The nurse should anticipate which actions in the patient's plan of care? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A woman with preeclampsia gave birth vaginally 1 hour ago. She is still receiving a magnesium sulfate infusion at 1 gm/hr. A major concern regarding the administration of magnesium sulfate at this time would be:

Correct Answer is D

Explanation

A woman with a history of congestive heart disease is 36 weeks pregnant. Which of the following findings should the nurse report to the primary health care practitioner?

Correct Answer is B

Explanation

During augmentation of labor with intravenous oxytocin (Pitocin), a multiparous client becomes pale and diaphoretic and complains of severe lower abdominal pain with a tearing sensation. An abnormal FHR tracing is noted on the monitor. The nurse should suspect:

When working with a woman who has just experienced a fetal demise you should offer supportive care, give her the opportunity to grieve, and provide for a chaplain to come in if the patient wants one. You know that the Chaplain is non-denominational and can also provide comforting words.

A woman is in the second stage of labor and has a spinal block in place for pain management. The nurse obtains the woman's blood pressure and notes that it is 20% lower than the baseline level. Which action should the nurse take?

The nurse is preparing for the admission of a 30 weeks' gestation patient experiencing vaginal bleeding with a suspected diagnosis of placenta previa. In anticipating the patient's needs, which of the following would be most appropriate for the nurse to include? Select all that apply.

A nurse is monitoring the labor of a patient who is receiving IV oxytocin (Pitocin) at 6 ml/hr. Which of the following clinical signs would lead the nurse to stop the infusion?

If the nurse suspects a patient has experienced anaphylactoid syndrome of pregnancy (amniotic fluid embolus), which of the following is the priority nursing intervention?

The nurse is caring for a pregnant woman who is HIV positive. While teaching her about the use of antiretroviral drugs, the nurse explains that these medications will