Level: Clinical
Difficulty: Medium
Subtopic: Pain management in labor
NCLEX: A 29-year-old client in labor and delivery is being evaluated for labor with epidural analgesia. Assessment data…
Maternal-newborn nursing Health Promotion and Maintenance Reduction of Risk Potential
Case Study
A 29-year-old client in labor and delivery is being evaluated for labor with epidural analgesia. Assessment data include contractions every 1 minute with no resting tone between contractions. Before a medication-related action, what must the nurse verify?
Question
A. Administer on schedule even when the client is unarousable.
B. Right client, medication, dose, route, time, allergies, indication, and relevant monitoring per protocol.
C. Skip allergy checks if the drug was given previously without reaction.
D. Delegate medication judgment to UAP to save time.
B. Right client, medication, dose, route, time, allergies, indication, and relevant monitoring per protocol.
C. Skip allergy checks if the drug was given previously without reaction.
D. Delegate medication judgment to UAP to save time.
Rationale
Correct answer: B. Right client, medication, dose, route, time, allergies, indication, and relevant monitoring per protocol.
Rationale: Medication safety requires full rights verification and monitoring; shortcuts increase error risk on the NCLEX and at the bedside.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Medication safety requires full rights verification and monitoring; shortcuts increase error risk on the NCLEX and at the bedside.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.