Health Promotion and Maintenance
88. A client, who is gravida 3, para 2, receives an epidural for labor pain relief. A nurse knows the client will need to have a Foley catheter placed if the epidural is in place longer than 1 hour. Which is the best rationale for this nursing action?
. The bladder fills more rapidly because of the medication used for the epidural.
. Her level of consciousness is such that she is in a trancelike state.
. The sensation of the bladder filling is diminished or lost.
. She is embarrassed to ask for the bedpan that frequently.
Test-Taking Tip
Restate this question as "What are the side effects of epidural anesthetics for a client in labor?"
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Basic Care and Comfort/Elimination
Health Promotion and Maintenance
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Answer 1 is incorrect because the bladder fills more rapidly because of the fluid bolus given before the epidural, not the medication used for the epidural. Answer 2 is incorrect because the epidural does not affect the level of consciousness. Answer 3 is correct because the sensation of the bladder filling is diminished or lost when the client has an epidural. Answer 4 is incorrect because there is no information in the stem that would indicate that she is embarrassed to ask for the bedpan that frequently. Even if that were the case, the bladder sensation is diminished when the client has an epidural.