The nurse is caring for a postpartal client who is exhibiting symptoms of a spinal headache 24 hours following delivery of a normal newborn. Prior to the anesthesiologist's arrival on the unit, which action should the nurse perform?

Cleanse the spinal injection site

Apply an abdominal binder

Insert an indwelling Foley catheter

Place procedure equipment at bedside

Answer and Explanation

The Correct Answer is D

A. Cleanse the spinal injection site:
Cleansing the spinal injection site is a routine part of maintaining proper hygiene during and after the administration of spinal anesthesia. However, if the client is experiencing symptoms of a spinal headache, the priority is to prepare for potential interventions by having the necessary equipment ready rather than focusing on the site itself.

B. Apply an abdominal binder:
Applying an abdominal binder is not directly related to addressing a spinal headache. Abdominal binders are typically used for providing support to the abdominal muscles after childbirth or surgery. It wouldn't be the primary intervention for a spinal headache.

C. Insert an indwelling Foley catheter:
Inserting an indwelling Foley catheter is not a direct intervention for addressing a spinal headache. Spinal headaches are related to cerebrospinal fluid leakage and positioning. While managing the patient's overall care is important, it may not be the immediate priority in this context.

D. Place procedure equipment at bedside:
This is the most appropriate action in the context of a postpartal client exhibiting symptoms of a spinal headache. Having the necessary procedure equipment, such as materials for a blood patch, ready at the bedside ensures preparedness for potential interventions by the anesthesiologist.

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Correct Answer is C

Explanation

A. Avoid alcohol, caffeine, and smoking: This is generally good advice during pregnancy to promote a healthy environment for the developing fetus, but it may not specifically address nausea.

B. Eliminate between meal snacks: While this might be suggested for some individuals, keeping something light on the stomach, like crackers, can sometimes help alleviate nausea.

C. Practice relaxation techniques when the nausea first begins: Relaxation techniques, such as deep breathing or meditation, can be beneficial in managing nausea, especially if stress or anxiety contributes to the symptoms.

D. Increase intake of fluids to 3 quarts daily: Staying hydrated is important during pregnancy, but drinking too much fluid at once might not necessarily alleviate nausea and could potentially make it worse.

A. Flaring of the nares B. Shallow and irregular respirations C. Respiratory rate of 50 breaths per minute D. Abdominal breathing with synchronous chest movement

Correct Answer is A

Explanation

A. Flaring of the nares:
Flaring of the nares is a clinical sign of respiratory distress in newborns. It indicates that the infant is working harder to breathe and is attempting to increase the size of the nostrils to get more air.

B. Shallow and irregular respirations:
Shallow and irregular respirations can be a sign of respiratory distress, but flaring of the nares is a more specific and immediate indication.

C. Respiratory rate of 50 breaths per minute:
While a respiratory rate of 50 breaths per minute might be within the normal range for a newborn, the overall clinical picture, including other signs of distress, should be considered.

D. Abdominal breathing with synchronous chest movement:
Abdominal breathing with synchronous chest movement is not a normal pattern for a newborn and could indicate respiratory distress.

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The nurse is caring for a postpartal client who is exhibiting symptoms of a spinal headache 24 hours following delivery of a normal newborn. Prior to the anesthesiologist's arrival on the unit, which action should the nurse perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What instruction is most important for the nurse to provide a client in the first trimester of pregnancy who is experiencing nausea?

Correct Answer is C

Explanation

The nurse is performing a newborn assessment. Which symptom, if present in a newborn, would indicate respiratory distress?

Correct Answer is A

Explanation

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