Question: A client is experiencing a sickle cell crisis during labor and delivery. What is the best nursing action?
1 Maintain IV fluid infusion and assess adequacy of hydration.
2 Administer a high concentration of oxygen.
3 Insert a Foley catheter and monitor hourly urine output.
4 Provide continuous sedation for pain relief.
Rationale: Adequate hydration is critical during stress periods for the client with sickle cell disease, and this is particularly true of a client in labor. Oxygen may or may not be ordered in low concentrations. A urinary retention catheter is not necessary at this time and would be a potential cause of infection. Although pain relief is important for both the sickling issues and the labor pains, continuous sedation would not be indicated, as this would be detrimental to the fetus.
This week’s NCLEX exam practice question came from:
Zerwekh: Illustrated Study Guide for the NCLEX-RN Examination, 7th Edition, Chapter 14, Page 268, Question 3