Maternal / Newborn Question #30

Question

A 12-year-old pediatric client complains of headache and nausea with any movement immediately following a lumbar puncture. Which action by the nurse will be most important for complaint of headache and nausea following a lumbar puncture?

Answers

  1. The nurse will document the findings and interpret the complaint as normal.
    • Rationale:
  2. The nurse will immediately contact the attending health care provider.
    • Rationale:
  3. The nurse will plan for a bolus of normal saline since it will help with the pain and nausea.
    • Rationale:
  4. The nurse will keep head of the bead elevated to prevent aspiration.
    • Rationale:

Overview

Explanation

Selection B is most important. The nurse should always report any type of neurologic status change which includes headache and nausea, papillary changes, swelling, bleeding, or CSF leakage at the site, nuchal pain or rigidity, tingling, loss of sensation, or sudden loss of bowel or bladder control. It is not to be overlooked or interpreted as normal as in Selection A (which is incorrect). Bolus of saline is not indicated (incorrect Selection C) and the client should be supine for one hour or as ordered… The question says immediately after the procedure, so HOB should be down.

Learning Outcomes

Test Taking Tip

Video Rationale