Select the 3 findings that would require immediate action from the nurse while the laboring mother is receiving an epidural anesthesia.

Dizziness

Reports of pain

Hypotension

Nausea

Fetal decelerations

Difficulty breathing

Answer and Explanation

Correct Answer : C,E,F

A. Dizziness: Often an early symptom of hypotension caused by epidural-induced vasodilation. It should be assessed promptly but is not as immediately life-threatening as hypotension or respiratory compromise.

B. Reports of pain: May indicate inadequate epidural coverage but is not life-threatening. Repositioning or additional dosing can typically address it without urgent intervention.

C. Hypotension: A serious and common complication of epidural anesthesia. It reduces uteroplacental perfusion and can result in fetal hypoxia. Immediate fluid bolus and possible vasopressor administration are indicated.

D. Nausea: Frequently accompanies hypotension but is not critical alone. It should prompt reassessment of blood pressure but does not necessitate emergency action unless combined with other symptoms.

E. Fetal decelerations: Reflect compromised fetal oxygenation, often secondary to maternal hypotension. Immediate interventions like repositioning, oxygen administration, or discontinuing oxytocin may be needed.

F. Difficulty breathing: Suggests high or total spinal anesthesia with ascending block affecting the diaphragm or intercostal muscles. This is a life-threatening emergency that requires immediate airway management and anesthesiology support.

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Correct Answer is B

Explanation

A. Record a minimal risk for falls, documenting the client's statement: Relying solely on the client's self-report without completing a comprehensive assessment may miss other critical risk factors for falls.

B. Continue to obtain client data needed to complete the fall risk survey: Gathering all necessary information using a standardized fall risk tool ensures a complete and objective evaluation, allowing appropriate interventions to be based on the total risk profile.

C. Inform the client that falls occur more often in the hospital than at home: Providing this information may be educational later, but it does not replace the need to finish the full assessment before drawing conclusions about risk.

D. Place the client on a high fall risk protocol because of advanced age: Age is a factor that increases fall risk, but it should not be the sole reason for assigning a high-risk status without evaluating the client's complete clinical picture.

A. The client is competent to sign the consent without impairment of judgment. B. Verifies that the client understands the procedure that is being performed. C. The client voluntarily grants permission for the procedure to be done. D. The surgeon has explained to the client why the surgery is necessary. E. The client understands the risks and benefits associated with the procedure.

Correct Answer is ["A","C"]

Explanation

A. The client is competent to sign the consent without impairment of judgment: By witnessing the signature, the nurse confirms the client appears alert, oriented, and capable of making an informed decision without evidence of coercion or impaired judgment.

B. Verifies that the client understands the procedure that is being performed: Ensuring client understanding of the procedure is the surgeon’s responsibility, not the nurse's; the nurse only verifies the client's signature and apparent willingness.

C. The client voluntarily grants permission for the procedure to be done: The nurse’s signature confirms that the client willingly and voluntarily signed the consent form without being forced or unduly influenced.

D. The surgeon has explained to the client why the surgery is necessary: Verifying that the surgeon has explained the surgery and its necessity falls within the surgeon's legal and ethical responsibilities, not the nurse’s role as a witness.

E. The client understands the risks and benefits associated with the procedure: It is the surgeon’s duty to discuss the risks and benefits; the nurse’s role is only to witness the signing, not to assess or confirm the depth of the client’s understanding.

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Select the 3 findings that would require immediate action from the nurse while the laboring mother is receiving an epidural anesthesia.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While the nurse is assessing an older client's fall risk, the client reports living at home alone and never falling. Which action should the nurse take?

Correct Answer is B

Explanation

After the nurse witnesses a preoperative client signing the surgical consent form, the nurse signs the form as a witness. Which is (are) the legal implication(s) of the nurse's signature on the client's surgical consent form? Select all that apply.

Correct Answer is ["A","C"]

Explanation

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