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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Determine fetal position by performing Leopold maneuvers:
Leopold maneuvers are used to determine the fetal position and presentation by palpating the mother's abdomen. While this information can be valuable, it's not the highest priority in a situation where there is significant vaginal bleeding.
B. Assess the fetal heart rate and client's contraction pattern:
This is the highest priority because it directly addresses the immediate concern. Monitoring the fetal heart rate and contraction pattern helps to assess the well-being of both the mother and the baby.
C. Confirm Rh and Coombs status for Rho(D) immunoglobulin administration:
While determining Rh status is important, it may not be the immediate priority in this situation. However, if there is a need for Rho(D) immunoglobulin administration, it should be addressed in a timely manner.
D. Perform sterile vaginal examination to determine dilatation:
Performing a sterile vaginal examination is an important aspect of assessing the progress of labor, but it may not be the highest priority when there is significant vaginal bleeding. The focus initially should be on assessing the fetal heart rate and contraction pattern.
Correct Answer is C
Explanation
A. Assign a practical nurse (PN) to reassess the client's vital signs:
While reassessing vital signs is important, the reported severe headache after delivery is a symptom that requires immediate attention. It's more appropriate for a licensed professional, such as the nurse or healthcare provider, to assess and decide the course of action.
B. Obtain a STAT hemoglobin and hematocrit:
While assessing hemoglobin and hematocrit can provide information about potential postpartum hemorrhage, it may not be the first action needed in this context. The severe headache suggests a possible neurological concern that should be addressed promptly.
C. Notify the healthcare provider of the assessment findings:
This is the most appropriate initial action. Severe headache after delivery, especially if the client had received anesthesia, could be indicative of post-dural puncture headache (PDPH). Prompt notification allows the healthcare provider to assess and decide on the necessary interventions.
D. Determine if the client received anesthesia during delivery:
Knowing the type of anesthesia is important for understanding potential complications. However, this information alone might not guide immediate actions. The focus should be on addressing the reported severe headache promptly.
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