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
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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Call for a STAT magnesium level. While obtaining a magnesium level is important to confirm magnesium toxicity, the priority action is to stop or reduce the infusion immediately to prevent further toxicity and respiratory depression.
B. Do nothing, this is the expected action of magnesium. Absent deep tendon reflexes, lethargy, and respiratory depression (RR 9) are signs of magnesium toxicity, not expected therapeutic effects. Immediate intervention is necessary to prevent worsening respiratory and cardiac complications.
C. Prepare to administer hydralazine. Hydralazine is used to treat hypertension in preeclampsia, but this patient’s blood pressure is not critically high, and the primary concern is magnesium toxicity, not hypertension. Administering hydralazine would not address the immediate life-threatening issue.
D. Decrease or Discontinue the magnesium sulfate infusion. The first action in magnesium toxicity is to stop or reduce the infusion to prevent further accumulation. If symptoms worsen, calcium gluconate, the antidote for magnesium toxicity, may be administered to reverse its effects, especially if respiratory depression progresses.
Correct Answer is A
Explanation
A. Perform vaginal exam and apply upward digital pressure to the presenting part. A prolapsed umbilical cord is an obstetric emergency that can lead to cord compression and fetal hypoxia. The priority intervention is for the nurse to manually lift the presenting part (usually the fetal head) off the cord to relieve pressure and restore blood flow. The nurse should maintain this position until an emergency cesarean section is performed.
B. Immediately turn the client to her side. Positioning changes, such as the knee-chest or Trendelenburg position, can help relieve pressure on the cord, but they are secondary to manually lifting the presenting part. While turning the client may assist, it is not the most immediate life-saving action.
C. Call the physician immediately. While notifying the provider is essential, relieving pressure on the umbilical cord takes priority. Delaying intervention to make a call could result in prolonged fetal hypoxia and compromise.
D. Place a moist, clean towel over the cord to prevent drying. Covering the cord with a moist towel helps prevent vasospasm and drying, but it does not relieve the compression that is cutting off oxygen to the fetus. The priority is to relieve pressure on the cord first before taking other measures.
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