Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
65. A client is in active labor at 38 weeks' gestation. She requests an epidural for labor pain. Which actions should a nurse take to prepare for this procedure? Select all that apply.
. Sit client upright on the side of the bed.
. Start a bolus of IV solution.
. Obtain baseline vital signs.
. Allow client to empty her bladder.
. Obtain an informed consent for the procedure.
. Perform a procedural pause before starting epidural.
Test-Taking Tip
Read the answers carefully. Eliminate Answer 5 completely because an informed consent is not the role of the nurse. The act of obtaining a client signature on the consent form is not the same as informed consent.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Alterations in Body Systems
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
. . . . .
Answer 1 is correct because the client must be sitting up before beginning the epidural procedure. Answer 2 is correct because an IV bolus must be infused before beginning an epidural procedure. Beginning the infusion is the first step because it takes the longest time and must be completed before the epidural procedure can be started. Answer 3 is correct because baseline vital signs must be recorded before beginning the procedure so that any changes in vital signs can be treated promptly. Answer 4 is correct because allowing a client to empty her bladder will make the procedure more comfortable for the client. In addition, after the epidural procedure, the client will lose sensation to her bladder and may be unable to void. Answer 5 is incorrect because nurses are not responsible for obtaining an informed consent. It is the responsibility of the physician or anesthesia provider to provide informed consent. Answer 6, performing a procedural pause, is the final step before beginning the epidural to ensure that this is the correct procedure and the correct client.