The nurse is caring for a laboring client who has requested an epidural. What are the nursing responsibilities prior to the procedure? Select all that apply
Assess FHR
Ensure an empty bladder
Give Ephedrine
Assess PTT
Assess client's blood pressure
Correct Answer : A,B,E
A. Assess FHR
To establish a baseline and detect any pre-existing distress.
B. Ensure an empty bladder
Prevents bladder distention during and after epidural.
C. Give Ephedrine
Only used if hypotension occurs after the epidural, not before.
D. Assess PTT
PTT not routinely required unless there's a bleeding disorder or anticoagulant use.
E. Assess client’s blood pressure
Needed to detect potential hypotension post-procedure.
Nursing Test Bank
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Related Questions
Correct Answer is D
Explanation
A. Obtain a slide sample and look for fluid:
May help but less reliable unless seeing ferning under microscope.
B. Test the vaginal fluid with Dextrostix:
Dextrostix checks for glucose, not amniotic fluid.
C. Perform a VE during contraction:
Increases risk of infection, especially if ROM is suspected.
D. Test vaginal fluid with Nitrazine paper:
Nitrazine paper checks pH; amniotic fluid is alkaline and turns the paper blue.
Correct Answer is D
Explanation
A. An enlarged uterus: Presumptive or probable sign; can occur in non-pregnancy conditions.
B. Quickening: Subjective, felt by mother; not definitive.
C. Positive pregnancy test: Probable sign, not definitive (false positives possible).
D. Fetal heart tones: A definitive (positive) sign of pregnancy.
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