TB - Chapter 19
During admission, a laboring patient tells the nurse, "I'm so afraid I'll need a cesarean section. I don't want to be asleep for surgery when my baby is born!" Which of the following nursing responses is most appropriate? Choice 1 "If a cesarean section is needed, that doesn't necessarily mean you'll need to go to sleep for surgery." Choice 2 "Your anesthesia provider will require that you go to sleep for surgery." Choice 3 "We'll do our best to make sure you deliver vaginally, so you don't need to have a cesarean section." Choice 4 "If you need a cesarean section, the anesthesia provider will awaken you as soon as possible after delivery so that you can see your baby quickly."
1 *Choice 1 "If a cesarean section is needed, that doesn't necessarily mean you'll need to go to sleep for surgery."* *Rationale 1 While general anesthesia may be needed for cesarean birth and for surgical intervention with some complications, in modern obstetrics, general anesthesia is used in less than 1% of all obstetric births.* Answer 1 true Choice 2 "Your anesthesia provider will require that you go to sleep for surgery." Rationale 2 General anesthesia may be needed for cesarean birth and for surgical intervention with some complications. However, in modern obstetrics, spinal anesthesia is often administered for delivery via cesarean section, while general anesthesia is used in less than 1% of all obstetric births. Answer 2 false Choice 3 "We'll do our best to make sure you deliver vaginally, so you don't need to have a cesarean section." Rationale 3 Reassuring the patient in this manner does not address the erroneous belief that general anesthesia is mandatory for women undergoing cesarean section. Answer 3 false Choice 4 "If you need a cesarean section, the anesthesia provider will awaken you as soon as possible after delivery so that you can see your baby quickly." Rationale 4 Reassuring the patient in this manner does not address the erroneous belief that general anesthesia is mandatory for women undergoing cesarean section. Answer 4 false
During her hospital admission, the laboring patient explicitly refused all pain medications and a labor epidural. Once dilated to 5 cm, the patient complains of intolerable discomfort and asks the nurse, "If I have an epidural, how will you make sure it doesn't hurt my baby?" The best response by the nurse is: Choice 1 "We'll monitor your baby continuously so we can recognize and treat any changes that may be related to the epidural." Choice 2 "Epidural anesthesia is very safe and there are no potential side effects that can affect your baby." Choice 3 "We'll assess your blood pressure every 15 minutes to make sure the epidural is not having any negative effects on your baby." Choice 4 Before your epidural is placed, we'll administer IV fluid to you in order to prevent the epidural from causing you problems."
1 *Choice 1 "We'll monitor your baby continuously so we can recognize and treat any changes that may be related to the epidural."* *Rationale 1 Continuous electronic fetal monitoring to assess fetal status is indicated in the care of pregnant women who receive epidural anesthesia and allows for a more direct assessment of fetal status than does frequent monitoring of maternal BP and pulse, which are also indicated in the care of this patient.* Answer 1 true Choice 2 "Epidural anesthesia is very safe and there are no potential side effects that can affect your baby." Rationale 2 While proficient administration and monitoring of epidural anesthesia allows for a high degree of safety with this technique, maternal hypotension associated with epidural anesthesia may produce harmful fetal effects. Answer 2 false Choice 3 "We'll assess your blood pressure every 15 minutes to make sure the epidural is not having any negative effects on your baby." Rationale 3 While frequent monitoring of maternal blood pressure and pulse are indicated in the care of a patient who receives a labor epidural, continuous electronic fetal monitoring is also indicated for assessment of fetal status and allows for a more direct fetal assessment. Answer 3 false Choice 4 Before your epidural is placed, we'll administer IV fluid to you in order to prevent the epidural from causing you problems." Rationale 4 While administration of a bolus of IV fluid is indicated in preparation for epidural placement and reduces the risk for maternal hypotension, this intervention neither guarantees the prevention of related complications nor allows for assessment of fetal status. Answer 4 false
The laboring patient has rated her pain at 9 on a scale of 1-10, and she requests IV pain medication. She has refused epidural anesthesia, but her certified nurse-midwife (CNM) has ordered butorphanol tartrate (Stadol) for administration to the patient. Which action should the nurse complete next? Choice 1 Advise the woman as to the actions and contraindications associated with butorphanol tartrate and obtain her consent for administration of the medication. Choice 2 Offer the woman epidural anesthesia once more and describe the effectiveness of this method of labor pain control. Choice 3 Obtain maternal vital signs and assess the fetal heart rate (FHR). Choice 4 Administer oxygen via face mask at 6 to 10 liters per minute.
1 *Choice 1 Advise the woman as to the actions and contraindications associated with butorphanol tartrate and obtain her consent for administration of the medication. * *Rationale 1 Prior to administration of medication, the nurse must explain the pharmacologic effects of the medication and obtain consent for administration.* Answer 1 true Choice 2 Offer the woman epidural anesthesia once more and describe the effectiveness of this method of labor pain control. Rationale 2 The woman has refused epidural anesthesia but is authorized to receive butorphanol tartrate. The nurse's next step is to advise the woman as to the actions and contraindications associated with butorphanol tartrate and obtain her consent for administration of the medication. Answer 2 false Choice 3 Obtain maternal vital signs and assess the fetal heart rate (FHR). Rationale 3 Prior to obtaining maternal vital signs and assessing FHR, the nurse should advise the woman as to the actions and contraindications associated with butorphanol tartrate and obtain her consent for administration of the medication. Answer 3 false Choice 4 Administer oxygen via face mask at 6 to 10 liters per minute. Rationale 4 Routine oxygen administration is not indicated for administration of butorphanol tartrate to an asymptomatic patient in labor. The nurse's next step is to advise the woman as to the actions and contraindications associated with butorphanol tartrate and obtain her consent for administration of the medication. Answer 4 false
The nurse has presented a teaching session on pain relief options to a prenatal class. Which patient statement indicates that additional teaching is needed? Choice 1 "An epidural can be continuous or one dose." Choice 2 "General anesthesia is usually recommended for a patient who delivers by way of cesarean section." Choice 3 "Narcotics can be given through a patient's epidural infusion catheter." Choice 4 "A pudendal block usually works well to control pain during episiotomy repair."
2 Choice 1 "An epidural can be continuous or one dose." Rationale 1 Epidural anesthesia can be administered in a single dose or via continuous infusion. Answer 1 false *Choice 2 "General anesthesia is usually recommended for a patient who delivers by way of cesarean section."* *Rationale 2 Compared to general anesthesia, spinal anesthesia is usually the anesthetic of choice indicated in the management of patients undergoing cesarean section.* Answer 2 true Choice 3 "Narcotics can be given through a patient's epidural infusion catheter." Rationale 3 To provide analgesia for approximately 24 hours after the birth, the analgesia provider may inject an opioid, such as morphine sulfate (Duramorph) or fentanyl (Sublimaze), into the epidural space immediately after the birth Answer 3 false Choice 4 "A pudendal block usually works well to control pain during episiotomy repair." Rationale 4 A pudendal block technique is given in the second stage of labor for the provision of perineal anesthesia for the latter part of the first stage of labor, the second stage, birth, and episiotomy repair. Answer 4 false
The patient at 39 weeks' gestation is undergoing a Cesarean birth due to breech presentation. General anesthesia is being used. Which potential challenge is most relevant to the anesthesia care of this patient? Choice 1 Hypotension due to the intense blockade of sympathetic fibers Choice 2 Difficulty with maternal intubation Choice 3 Broad ligament hematoma Choice 4 Fetal depression that is fetal depression inversely proportional to maternal anesthetic depth and duration
2 Choice 1 Hypotension due to the intense blockade of sympathetic fibers Rationale 1 Regional anesthesia, including epidural anesthesia, is associated with an intense blockade of sympathetic fibers that results in a high incidence of hypotension. Answer 1 false *Choice 2 Difficulty with maternal intubation* *Rationale 2 Difficulty with maternal intubation is a primary challenge of general anesthesia care for pregnant patients.* Answer 2 true Choice 3 Broad ligament hematoma Rationale 3 Broad ligament hematoma is a complication associated with pudendal blockade. Answer 3 false Choice 4 Fetal depression that is fetal depression inversely proportional to maternal anesthetic depth and duration Rationale 4 Fetal depression associated with general anesthesia is directly proportional to maternal anesthetic depth and duration. Answer 4 false
A laboring patient has received an order for epidural anesthesia. In order to prevent the most common complication associated with this procedure, the nurse would expect to do which of the following? Choice 1 Observe fetal heart rate variability. Choice 2 Rapidly infuse 500-1,000 ml of intravenous fluids. Choice 3 Place the patient in the semi-Fowler's position. Choice 4 Teach the patient appropriate breathing techniques.
2 Choice 1 Observe fetal heart rate variability. Rationale 1 Administering a fluid bolus prior to an epidural generally prevents maternal hypotension, which is the most common side effect of an epidural. Answer 1 false *Choice 2 Rapidly infuse 500-1,000 ml of intravenous fluids.* *Rationale 2 Administering a fluid bolus prior to an epidural generally prevents maternal hypotension, which is the most common disadvantage to the procedure.* Answer 2 true Choice 3 Place the patient in the semi-Fowler's position. Rationale 3 Administering a fluid bolus prior to an epidural generally prevents maternal hypotension, which is the most common disadvantage to the procedure. Answer 3 false Choice 4 Teach the patient appropriate breathing techniques. Rationale 4 Administering a fluid bolus prior to an epidural generally prevents maternal hypotension, which is the most common disadvantage to the procedure. Answer 4 false
The charge nurse is reviewing the plans of care for four laboring patients. Which care plan requires immediate reconsideration for revision? Choice 1 Administration of epidural anesthesia to a woman who is in the first stage of labor and has a shellfish allergy Choice 2 Administration of a spinal anesthetic to a woman who is scheduled for vaginal delivery of her baby Choice 3 Administration of epidural anesthesia to a woman with a history of vomiting secondary to hyperemesis gravidarum Choice 4 Administration of a spinal anesthetic to a woman with a history of irritable bowel syndrome (IBS)
3 Choice 1 Administration of epidural anesthesia to a woman who is in the first stage of labor and has a shellfish allergy Rationale 1 A lumbar epidural relieves pain associated with the first and second stages of labor. An allergy to shellfish is not a contraindication to epidural anesthesia. Answer 1 false Choice 2 Administration of a spinal anesthetic to a woman who is scheduled for vaginal delivery of her baby Rationale 2 Spinal anesthetics may be used to provide anesthesia for cesarean birth and occasionally for vaginal birth. Answer 2 false *Choice 3 Administration of epidural anesthesia to a woman with a history of vomiting secondary to hyperemesis gravidarum* *Rationale 3 Contraindications to epidural anesthesia include severe hypovolemia of any etiology. This patient with hyperemesis gravidarum should be evaluated for severity of dehydration prior to administration of epidural anesthesia.* Answer 3 true Choice 4 Administration of a spinal anesthetic to a woman with a history of irritable bowel syndrome (IBS) Rationale 4 Irritable bowel syndrome (IBS) does not represent a contraindication to spinal anesthesia. Answer 4 false
After receiving nalbuphine hydrochloride (Nubain), a woman's labor progresses rapidly, and the baby is born less than one hour later. The baby exhibits signs of respiratory depression. Which medication should the nurse be prepared to administer to the newborn? Choice 1 Fentanyl (Sublimaze) Choice 2 Butorphanol tartrate (Stadol) Choice 3 Naloxone (Narcan) Choice 4 Pentobarbital (Nembutal)
3 Choice 1 Fentanyl (Sublimaze) Rationale 1 Narcan is the only choice that is an opiate antagonist, which would reverse the effects of the Nubain. Answer 1 false Choice 2 Butorphanol tartrate (Stadol) Rationale 2 Narcan is the only choice that is an opiate antagonist, which would reverse the effects of the Nubain. Answer 2 false *Choice 3 Naloxone (Narcan)* *Rationale 3 Narcan is the only choice that is an opiate antagonist, which would reverse the effects of the Nubain.* Answer 3 true Choice 4 Pentobarbital (Nembutal) Rationale 4 Narcan is the only choice that is an opiate antagonist, which would reverse the effects of the Nubain. Answer 4 false
The laboring patient requests pain medication. Her contractions are lasting 20-30 seconds and are occurring every 8-20 minutes. The nurse would explain that analgesics given at this time would likely cause: Choice 1 Fetal respiratory depression. Choice 2 Decreased analgesic effectiveness at the end of labor. Choice 3 Maternal hypotension. Choice 4 Prolonged labor.
4 Choice 1 Fetal respiratory depression. Rationale 1 Pain medication given before established labor does not cause fetal respiratory depression unless the mother delivers within an hour of receiving the medication. This is not likely if labor is not established. Answer 1 false Choice 2 Decreased analgesic effectiveness at the end of labor. Rationale 2 Medication given early in the labor process does not become less effective at the end of labor. Answer 2 false Choice 3 Maternal hypotension. Rationale 3 Analgesics might lower the blood pressure, but this effect does not cause the contraction pattern to be altered. Answer 3 false *Choice 4 Prolonged labor.* *Rationale 4 Pain medication given before labor becomes established is likely to prolong the labor process.* Answer 4 true
The anesthesia provider has just administered an epidural anesthetic in a laboring patient and local anesthesia is continuously infusing via the epidural catheter. Suddenly, the patient asks, "Why are my ears ringing?" What is the most likely cause of the patient's complaint? Choice 1 Hypotension Choice 2 Allergic reaction Choice 3 Dehydration Choice 4 Local anesthetic toxicity
4 Choice 1 Hypotension Rationale 1 Although maternal hypotension is associated with epidural anesthesia, a sensation of ringing in the ears is associated with local anesthetic toxicity. Answer 1 false Choice 2 Allergic reaction Rationale 2 Sensation of ringing in the ears is associated with local anesthetic toxicity. Answer 2 false Choice 3 Dehydration Rationale 3 Sensation of ringing in the ears is associated with local anesthetic toxicity. Answer 3 false *Choice 4 Local anesthetic toxicity* *Rationale 4 Sensation of ringing in the ears is associated with local anesthetic toxicity.* Answer 4 true
Prior to receiving lumbar epidural anesthesia, the nurse would anticipate placing the laboring patient in which of the following positions? Choice 1 On her right side in the center of the bed with her back curved Choice 2 Lying prone with a pillow under her chest Choice 3 On her left side with the bottom leg straight and the top leg slightly flexed Choice 4 Sitting on the edge of the bed with her back slightly curved and her feet on a stool
4 Choice 1 On her right side in the center of the bed with her back curved Rationale 1 Especially in pregnant women, this position is not ideal for facilitating access to the epidural space. Answer 1 false Choice 2 Lying prone with a pillow under her chest Rationale 2 This position is not consistent with access to the epidural spaces. Answer 2 false Choice 3 On her left side with the bottom leg straight and the top leg slightly flexed Rationale 3 This position is not consistent with access to the epidural spaces. Answer 3 false *Choice 4 Sitting on the edge of the bed with her back slightly curved and her feet on a stool* *Rationale 4 Sitting on the edge of the bed with the back slightly curved and the feet on a stool allows the epidural spaces to be accessed more easily.* Answer 4 true
A client in labor received a dose of meperidine (Demerol) for pain control. Which assessment findings should the nurse suspect are adverse effects of this medication? Select all that apply. 1. Nausea 2. Pruritus 3. Sedation 4. Bradycardia 5. Hypotension
Answer: 1, 2, 3 Explanation *1. Nausea is an adverse effect of meperidine.* *2. Pruritus is an adverse effect of meperidine.* *3. Sedation is an adverse effect of meperidine.* 4. Bradycardia is an adverse effect of fentanyl. 5. Hypotension is an adverse effect of nalbuphine hydrochloride and fentanyl.
A client in labor needs an emergency cesarean section. What should the nurse include when preparing this client for rapid induction of labor? Select all that apply. 1. Place a wedge under the right hip. 2. Insert an indwelling urinary catheter. 3. Insert an intravenous infusion catheter. 4. Provide a bolus of 1 L of intravenous fluid. 5. Preoxygenate with 3 to 5 minutes of 100% oxygen.
Answer: 1, 2, 3, 5 Explanation: *1. Before induction of anesthesia, a wedge is placed under the woman's right hip to displace the uterus and prevent vena caval compression in the supine position.* *2. An indwelling bladder catheter is usually inserted before surgery for women undergoing cesarean birth.* *3. Before induction of anesthesia, intravenous fluids are started so that access to the intravascular system is immediately available.* 4. A bolus of intravenous fluid is provided prior to an epidural; however, it is not indicated for general anesthesia. *5. Before induction of anesthesia, the client should be preoxygenated with 3 to 5 minutes of 100% oxygen.*
The nurse is preparing a client in labor for an emergency cesarean section. Which medication should the nurse expect to be prescribed to prevent the effects of aspirated gastric contents? Select all that apply. 1. Famotidine (Pepcid) 2. Cimetidine (Tagamet) 3. Omeprazole (Prilosec) 4. Pantoprazole (Protonix) 5. Metoclopramide (Reglan)
Answer: 1, 2, 5 Explanation: *1. Prophylactic antacid therapy to reduce the acidic content of the stomach before general anesthesia is common practice. Famotidine is used to help empty gastric contents.* *2. Prophylactic antacid therapy to reduce the acidic content of the stomach before general anesthesia is common practice. Cimetidine is used to help empty gastric contents.* 3. Omeprazole is a proton pump inhibitor and is not identified as being used before general anesthesia to help empty gastric contents. 4. Pantoprazole is a proton pump inhibitor and is not identified as being used before general anesthesia to help empty gastric contents. *5. Prophylactic antacid therapy to reduce the acidic content of the stomach before general anesthesia is common practice. Metoclopramide is used to help empty gastric contents.*
Which nursing action can prevent or detect common side effects of epidural anesthesia? Select all that apply. 1. Preloading the client with a rapid infusion of IV fluids 2. Continuing the client on oral fluids only to prevent hypotension 3. Assisting the client to empty the bladder before the anesthesia is started 4. Use of intermittent fetal heart rate (FHR) monitoring so the client can use the birthing ball 5. Monitoring the fetal heart rate (FHR) for late deceleration and decrease in rate
Answer: 1, 3, 5 Explanation: *1. Hypotension can be prevented by preloading with rapid IV infusion followed by continuous IV infusion.* 2. Hypotension can be prevented by preloading with rapid IV infusion followed by continuous IV infusion. The amount of oral fluids that would be required to prevent hypotension makes this approach inappropriate for the client in labor. *3. The epidural decreases the urge to urinate. The client's bladder should be assessed frequently for distention.* 4. Hypotension can be prevented by preloading with rapid IV infusion followed by continuous IV infusion. Variability of FHR and late decelerations can occur if maternal hypotension occurs. Continuing FHR monitoring is essential. *5. Hypotension can be prevented by preloading with rapid IV infusion followed by continuous IV infusion. Variability of FHR and late decelerations can occur if maternal hypotension occurs. Continuing FHR monitoring is essential.*
A client in labor is having a pudendal block. For which adverse effects should the nurse assess this client? Select all that apply. 1. Infection 2. Spinal headache 3. Perforated rectum 4. Sciatic nerve trauma 5. Broad ligament hematoma
Answer: 3, 4, 5 Explanation: 1. An infection is not associated with a pudendal block. 2. A spinal headache is not associated with a pudendal block. *3. Disadvantages of the pudendal block include possible perforation of the rectum.* *4. Disadvantages of the pudendal block include possible trauma to the sciatic nerve.* *5. Disadvantages of the pudendal block include possible broad ligament hematoma*
A client in labor wants to have a medication-free birth. What should the nurse include when discussing alternatives to pain medication with this client? 1. Emphasize that no medication will be given. 2. Review that the use of medications allows for rest and less fatigue. 3. Explain that pain relief will allow a more enjoyable birth experience. 4. Summarize how maternal pain and stress can have a more adverse effect on the fetus than would a small amount of analgesia.
Answer: 4 Explanation: 1. It is important to respect the client's wishes when possible. Once the effects are explained, it is still the client's choice whether to receive medication. 2. While pain relief can allow the client to be less fatigued, it might be the view of the nurse but not the client. 3. While pain relief can lead to a more enjoyable experience, it might be the view of the nurse but not the client. *4. The decision not to medicate should be an informed one, and it is possible that the client does not know about the effects pain and stress can have on the fetus. Once the effects are explained, it is still the client's choice whether to receive medication.*
Following spinal anesthesia for delivery of her baby, a woman reports an inability to void urine. As the nurse palpates the woman's bladder the woman says, "It's been five hours since I had my spinal and I still can't empty my bladder. Do I have nerve damage?" How should the nurse respond? Choice 1 "Spinal anesthesia can sometimes cause nerve damage." Choice 2 "It may be several hours before you're able to control your urination." Choice 3 "You should be able to control your bladder by now. I'll ask the anesthesia provider to visit with you." Choice 4 "You are probably dehydrated. Please increase your water intake."
Choice 1 "Spinal anesthesia can sometimes cause nerve damage." Rationale 1 Although nerve damage is a rare occurrence in relation to spinal anesthesia, there is no objective data to suggest that this woman has experienced nerve damage. Restoration of bladder control may take 8 to 12 hours following a spinal anesthetic. Answer 1 false *Choice 2 "It may be several hours before you're able to control your urination."* *Rationale 2 Restoration of bladder control may take 8 to 12 hours following a spinal anesthetic.* Answer 2 true Choice 3 "You should be able to control your bladder by now. I'll ask the anesthesia provider to visit with you." Rationale 3 Restoration of bladder control may take 8 to 12 hours following a spinal anesthetic. Answer 3 false Choice 4 "You are probably dehydrated. Please increase your water intake." Rationale 4 There is no data to suggest the woman is dehydrated. Rather, she is likely demonstrating a common side effect of spinal anesthesia. Restoration of bladder control may take 8 to 12 hours following a spinal anesthetic. Answer 4 false
The nurse is caring for a laboring patient who is receiving continuous epidural anesthesia via infusion. The maternal blood pressure decreases from 132/78 to 78/42. Which intervention should the nurse implement first? Choice 1 Increase the flow rate of infusion of intravenous crystalloid solution. Choice 2 Verify the patient is positioned to promote left uterine displacement. Choice 3 Administer oxygen. Choice 4 Administer ephedrine 5 to 10 mg intravenously.
Choice 1 Increase the flow rate of infusion of intravenous crystalloid solution. Rationale 1 If hypotension occurs secondary to epidural anesthesia, the nurse increases the IV flow rate, ensures or verifies left uterine displacement, and administers oxygen. If blood pressure is not restored in 1 to 2 minutes, ephedrine, 5 to 10 mg IV, is administered. Answer 1 true Choice 2 Verify the patient is positioned to promote left uterine displacement. Rationale 2 If hypotension occurs secondary to epidural anesthesia, the nurse increases the IV flow rate, ensures or verifies left uterine displacement, and administers oxygen. If blood pressure is not restored in 1 to 2 minutes, ephedrine, 5 to 10 mg IV, is administered. Answer 2 false *Choice 3 Administer oxygen* Rationale 3 If hypotension occurs secondary to epidural anesthesia, the nurse increases the IV flow rate, ensures or verifies left uterine displacement, and administers oxygen. If blood pressure is not restored in 1 to 2 minutes, ephedrine, 5 to 10 mg IV, is administered. Answer 3 false Choice 4 Administer ephedrine 5 to 10 mg intravenously. Rationale 4 If hypotension occurs secondary to epidural anesthesia, the nurse increases the IV flow rate, ensures or verifies left uterine displacement, and administers oxygen. If blood pressure is not restored in 1 to 2 minutes, ephedrine, 5 to 10 mg IV, is administered. Answer 4 false.
