The nurse is caring for a woman with epidural anesthesia for pain control during a vaginal delivery. A risk for injury related to epidural anesthesia has been identified by the nursing staff. What interventions are appropriate for the nurse to implement related to this diagnosis? (Select all that apply.)
a. Assess leg movement and sensation before ambulating.
b. Administer antibiotic as ordered.
c. Observe for signs of impending birth.
d. Provide sacral pressure as needed.
e. Assess fetal position frequently.
ANS: A, C
To prevent the risk for injury related to epidural anesthesia the nurse should asses for movement, sensation, and leg strength before ambulating, ambulate cautiously with an assistant, assist the woman to change positions regularly, and observe for signs that birth may be near: increase in bloody show, perineal bulging, and/or crowning.
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