Author Question: A patient had an epidural inserted 2 hours ago. It is functioning well, the patient is stable, and ... (Read 31 times)

newbem · **on:** Jun 27, 2018

A patient had an epidural inserted 2 hours ago. It is functioning well, the patient is stable, and labor is progressing.

Which parts of the assessment have the highest priority? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Assess blood pressure every hour.
2. Assess the pulse rate every hour.
3. Palpate the bladder.
4. Auscultate the lungs.
5. Assess the reflexes.

Question 2

A Chinese woman who is 12 weeks pregnant reports to the nurse that ginseng and bamboo leaves help reduce her anxiety. How should the nurse respond to this patient?

1. Advise the patient to give up the bamboo leaves but to continue taking ginseng.
2. Advise the patient to give up all herbal remedies during the first trimester except for ginger.
3. Tell the patient that her remedies have no scientific foundation.
4. Assess where the patient obtains her remedy, and investigate the source.

momolu · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

1,3
Rationale 1: If blood pressure is stable, it should be assessed at least hourly, because the epidural can cause hypotension.
Rationale 2: This is done, but is not a priority.
Rationale 3: The patient loses the feeling and urge to urinate with an epidural.
Rationale 4: This done, but is not a first priority.
Rationale 5: Assessing reflexes is not a priority with an epidural.

Answer to Question 2

2
Rationale 1: It would be wrong to advise the patient to continue taking ginseng, which is not recommended during pregnancy.
Rationale 2: In general, it is best to advise pregnant women not to ingest any herbs, except ginger, during the first trimester of pregnancy.
Rationale 3: Some remedies do have scientific foundation, so it is not appropriate to instruct the patient that none do.
Rationale 4: It is outside the nurse's scope to assess the source of the herbs.