HESI - OB, Epidural Catheter Insertion
A patient who is gravida 4, para 3 at 39 weeks' gestation is being induced for gestational hypertension. The patient has a prior history of deep vein thrombosis and has been receiving low-molecular-weight heparin during the pregnancy. How many hours should the patient be off her low-molecular-weight heparin before an epidural is safe? A. Neuraxial analgesics and anesthetics should be withheld until 10 to 12 hours after the last prophylactic dose or 24 hours after the last therapeutic dose. B. Neuraxial analgesics and anesthetics should be withheld until 14 to 16 hours after the last prophylactic dose or 24 hours after the last therapeutic dose. C. Neuraxial analgesics and anesthetics should be withheld until 10 to 12 hours after the last prophylactic dose or 48 hours after the last therapeutic dose. D. Neuraxial analgesics and anesthetics should be withheld until 10 to 12 hours after the last prophylactic dose or 36 hours after the last therapeutic dose.
A. Neuraxial analgesics and anesthetics should be withheld until 10 to 12 hours after the last prophylactic dose or 24 hours after the last therapeutic dose. Rationale: For pregnant patients on low-molecular-weight heparin, neuraxial analgesics and anesthetics should be withheld until 10 to 12 hours after the last prophylactic dose or 24 hours after the last therapeutic dose to decrease the risk of bleeding. Waiting 14 to 16 hours after the last prophylactic dose of low-molecular-weight heparin is not necessary and could delay an epidural. Waiting 36 or 48 hours after the last therapeutic dose of low-molecular-weight heparin is also not necessary and could further delay an epidural.
The anesthesia provider asks the nurse to obtain a vial of medication for a patient's epidural. As is standard with all medications, the nurse should check the name, dose, and expiration date on the medication vial before giving it to the anesthesia provider. Which additional information should the nurse check because the medication is used for epidural administration? A. Whether it is preservative free B. Whether it is short acting C. Whether it is long acting D. Whether it is epinephrine free
A. Whether it is preservative free Rationale: The nurse must be sure that the medication being administered via the epidural is preservative free because a preservative could cause nerve damage. Although the nurse should know if the medication is long acting or short acting, this knowledge is not important immediately before handing the medication to the anesthesia provider. Anesthesia providers commonly administer a small dose of lidocaine with epinephrine as the test dose to ensure that the catheter is not in a blood vessel. Epinephrine would cause the pulse rate to increase.
A patient is gravida 2, para 1 at 40 weeks' gestation and is 6 cm dilated and 0 station. An hour after receiving an epidural, the patient complains of feeling pressure and is found to be 8 cm dilated and +2 station. The patient asks the nurse why she is feeling pressure even with an epidural. Which is the best response by the nurse? A. "Pressure and pain are normal even with an epidural." B. "It's normal to feel pressure since the baby is lower in the birth canal." C. "You may need more medication through your epidural so you don't feel any pressure." D. "Feeling pressure can indicate a problem. I will notify your practitioner."
B. "It's normal to feel pressure since the baby is lower in the birth canal." Rationale: Feeling pressure with an epidural, especially as the baby descends into the birth canal is normal; however, if the patient is feeling pain, she may need additional medication through her epidural catheter. Pressure helps the patient push in the second stage of labor. If the patient is not in pain, giving more medication to eliminate the feeling of pressure may result in ineffective pushing. Because feeling pressure is normal, notifying the practitioner is not necessary.
The anesthesia provider requests that the nurse position a laboring patient in a sitting position with the knees flexed and shoulders parallel for epidural placement. The nurse asks the patient to curve her back outward toward the anesthesia provider. What is the purpose of this positioning? A. It places the patient closer to the anesthesia provider for easier placement of the epidural catheter. B. It opens the space between the vertebrae for easier placement of the epidural catheter. C. It helps the nurse or support person maintain the patient in position to prevent adverse effects from the epidural. D. It helps the nurse see the insertion site and offer assistance as needed to the anesthesia provider.
B. It opens the space between the vertebrae for easier placement of the epidural catheter. Rationale: Arching the back outward opens the space between the vertebrae, allowing access to the epidural space. The patient should be easily accessible to the anesthesia provider, and the nurse does need to help her stay in one position; however, arching the back does not contribute to these goals. The patient is the nurse's priority during the epidural insertion procedure; therefore, the nurse does not need to see the insertion site to assist the anesthesia provider with the procedure.
Before administration of an epidural, the nurse administers an ordered bolus of IV fluids. The nurse explains to the student nurse that the IV bolus is administered to help avoid a sympathetic response to the anesthetic. Which sympathetic responses does this include? A. Maternal hypertension and FHR changes B. Maternal fever and FHR changes C. Maternal hypotension and FHR changes D. Maternal hypertension and fever
C. Maternal hypotension and FHR changes Rationale: Maternal hypertension is not a sympathetic response to an epidural anesthetic. Although an association exists between epidural analgesia and maternal fever, the cause is not a sympathetic response, and reasons for the association remain unknown. Maternal hypotension and FHR changes may result from the sympathetic response to the anesthetic. A preload of IV fluids may help prevent this response.
A patient who is gravida 2, para 0 has a baseline blood pressure of 124/72 mm Hg, a pulse of 88 beats per minute, and 24 respirations per minute. The patient has just received a test dose of lidocaine with epinephrine. The nurse notes that the patient's pulse has increased to 120 beats per minute and that her blood pressure is now elevated to 140/86 mm Hg. Which nursing intervention is most appropriate? A. Increase the rate of the patient's IV infusion to flush out the medication. B. Initiate oxygen therapy to prevent poor uteroplacental perfusion. C. Notify the anesthesia provider of probable venous cannulation of the epidural catheter. D. Notify the practitioner in case an emergency birth is required.
C. Notify the anesthesia provider of probable venous cannulation of the epidural catheter. Rationale: Lidocaine with epinephrine is commonly used as a test dose via the epidural catheter because of its sympathomimetic characteristics. These effects are transitory and do not require emergency management. However, the anesthesia provider should be notified because this patient's response indicates that unintentional epidural vein cannulation has occurred, and the catheter needs to be adjusted or replaced. Immediate adjustment of the epidural catheter is the correct intervention; oxygen administration is not appropriate. Increasing the IV rate to flush out the medication is not required unless the patient is hypotensive. Her symptoms indicate that unintentional epidural vein cannulation has occurred, which is not an emergency birth scenario.
Three hours after a laboring patient is admitted, her cervix has dilated to 5 cm and is 100% effaced; the fetal station is -1. The FHR pattern is Category 1 (normal). The patient reports persistent low back pain and is having difficulty relaxing between contractions. She has been using breathing techniques. However, she no longer finds them effective and rates her pain as 9 on a scale of 0 to 10. The patient asks her nurse if she might benefit from an epidural. Epidural analgesia would provide which benefit for this patient? A. Labor may progress better if the patient is able to maintain one position. B. The patient's contractions may slow and cause less pain. C. The active phase of labor may progress at a faster rate if the patient is able to relax. D. The patient will be ready for a cesarean delivery.
C. The active phase of labor may progress at a faster rate if the patient is able to relax. Rationale: The patient's labor progress during the active phase may benefit from increased relaxation with the relief of pain. Epidural infusion is a method to control the laboring patient's pain and may slow contractions immediately after administration secondary to the fluid bolus received before the epidural. Slowing the contractions is not an advantage of epidural analgesia. Decreased mobility is a disadvantage of the epidural block because it decreases the patient's options for positions that could improve fetal descent and rotation through the pelvis. Patients with epidurals should change positions frequently. This case scenario has no indications for cesarean delivery. Additionally, epidural use has not been found to lead to an increased incidence of cesarean delivery.
A laboring patient received an epidural infusion approximately 2 hours ago and is resting comfortably. However, the nurse notices that the patient is continually rubbing her nose and scratching her abdomen. When asked, the patient states, "I guess I must be allergic to something; the itching started about an hour ago." What is the most appropriate response? A. "Have you ever had this problem before? I doubt it's related to anything here." B. "You're probably having an allergic reaction. I'll let the anesthesia provider know about it." C. "You're probably sensitive to the detergent they use to wash our linens. Let me ask the practitioner if we can give you an antihistamine." D. "The itching is a fairly common reaction to the medication in your epidural. Would you like me to talk to the anesthesia provider about some medicine to provide relief?"
D. "The itching is a fairly common reaction to the medication in your epidural. Would you like me to talk to the anesthesia provider about some medicine to provide relief?" Rationale: Adverse effects of opioids administered by the epidural and intrathecal routes include nausea, vomiting, pruritus, urinary retention, and delayed respiratory depression. Antipruritics and opioid antagonists are used to relieve these signs and symptoms. Pruritus is the most common reaction to IV and intraspinal opioids. An allergic reaction could involve throat swelling, welts, or hives as well as itching. The patient's allergies to medications should have been thoroughly reviewed before insertion of the epidural. Sensitivity to the linens is not an appropriate consideration in this case. The patient may experience pruritus related to opioids any number of times, and previous experience or disassociation from the procedure is irrelevant.
A full-term multiparous patient in labor has just requested an epidural. Which absolute contraindication would prevent the patient from receiving it? A. Conditions such as preeclampsia and diabetes B. Allergy to betadine C. Allergy to fentanyl D. Maternal inability to cooperate during the procedure
D. Maternal inability to cooperate during the procedure Rationale: A maternal inability to cooperate during the procedure is an absolute contraindication because of the risk of nerve damage if the patient moves during insertion. Preeclampsia is not a contraindication unless the patient develops associated thrombocytopenia. Diabetes is not a contraindication to an epidural. An allergy to betadine is not a contraindication because other non-betadine solutions can be used to clean the insertion site. Although fentanyl is sometimes given through epidural catheters to enhance pain relief, it is not the only medication used for epidural pain relief.
A laboring patient who is gravida 2, para 0 at 39 weeks' gestation is dilated 7 cm and has an epidural. The patient states that she has left-side pain that is an 8 on a scale of 0 to 10 and that she needs more pain relief. The nurse notifies the anesthesia provider, who is busy and asks the nurse to give the patient a 5-ml bolus of bupivacaine via the epidural pump. What should be the nurse's next action? A. Have the anesthesia provider write an order for the medication. B. Place a verbal order in the computer because the anesthesia provider is busy. C. Give the medication and have the anesthesia provider put the order in the computer when not busy. D. Notify the anesthesia provider that you cannot give the bolus of medication.
D. Notify the anesthesia provider that you cannot give the bolus of medication. Rationale: Only a licensed anesthesia provider should increase or decrease the epidural infusion dose, administer boluses of the medication, restart the infusion after it has been stopped, and obtain informed consent. Administering an epidural bolus is not within the nurse's scope of practice, and he or she should notify the anesthesia provider
