The scrub nurse is preparing for an emergency cesarean section for a client who has a positive HIV test result. The nurse plans care knowing that which of these precautions will be implemented?

Choice A reason:

Double gloving is a recommended precaution for health care workers who are exposed to blood or body fluids of clients who have a positive HIV test result. Double gloving can reduce the risk of needlestick injuries and transmission of HIV or other bloodborne pathogens.

Choice B reason:

Placing instruments in closed containers at completion of surgery is not a specific precaution for clients who have a positive HIV test result. It is a standard practice for all surgical procedures to prevent contamination and infection. Placing instruments in closed containers does not protect the health care workers from exposure to blood or body fluids during surgery.

Choice C reason:

Wearing shoe covers in addition to personal protective equipment is not a specific precaution for clients who have a positive HIV test result. It is a standard practice for all surgical procedures to prevent contamination and infection. Wearing shoe covers does not protect the health care workers from exposure to blood or body fluids during surgery.

Choice D reason:

Using instruments only from specially marked trays is not a specific precaution for clients who have a positive HIV test result. It is a standard practice for all surgical procedures to prevent contamination and infection. Using instruments only from specially marked trays does not protect the health care workers from exposure to blood or body fluids during surgery.

Choice A reason:

The client reports numbness in his right leg. This is not a cause for immediate intervention by the nurse, because numbness is an expected effect of spinal anesthesia. Spinal anesthesia blocks the nerve impulses from the lower extremities, lower abdomen, pelvic, and perineal regions, resulting in loss of sensation and movement.

Choice B reason:

The client has a blood pressure of 90/60 mm Hg. This is not a cause for immediate intervention by the nurse, because mild hypotension is a common side effect of spinal anesthesia. Spinal anesthesia causes vasodilation and decreases the sympathetic tone, leading to reduced blood pressure. The nurse should monitor the client's vital signs and fluid status, and administer vasopressors if needed.

Choice C reason:

The client complains of a headache when sitting up. This is a cause for immediate intervention by the nurse, because it may indicate a post-dural puncture headache (PDPH) PDPH is a complication of spinal anesthesia that occurs when the dura mater is punctured by the needle, causing cerebrospinal fluid (CSF) to leak and create a pressure gradient between the intracranial and spinal compartments. The nurse should assess the client's pain level, position the client flat or with a slight head elevation, administer analgesics and fluids, and notify the anesthesiologist.

Choice D reason:

The client has difficulty voiding after surgery. This is not a cause for immediate intervention by the nurse, because urinary retention is a common problem after spinal anesthesia. Spinal anesthesia affects the bladder function by inhibiting the micturition reflex and impairing the sensation of bladder fullness. The nurse should monitor the client's urine output, bladder distension, and fluid intake, and assist with catheterization if needed.