A nurse is caring for a client who is receiving an epidural for labor pain. Which of the following actions should the nurse take?
Explanation & Rationale
A. Position the client in a lithotomy position during the epidural procedure: Epidurals are typically administered with the client in a sitting position or lying on their side with the back arched (fetal position) to allow access to the lumbar spine. Lithotomy position is not used for epidural placement. B. Monitor the client's bladder for distention: Epidural anesthesia can decrease bladder sensation and the ability to void, increasing the risk of urinary retention. Monitoring for bladder distention and assisting with catheterization if needed is an essential nursing action to prevent complications. C. Administer oxygen to the client at 2 L/min via face mask: Oxygen is not routinely administered to clients receiving an epidural unless there is evidence of maternal hypoxia or fetal distress. Routine oxygen is not required and should be based on assessment findings. D. Limit turning the client during labor: While care must be taken to maintain the epidural catheter, clients can still be repositioned to promote comfort and labor progression. Turning is not prohibited, but care should be taken to avoid dislodging the catheter.