A client is receiving an epidural anesthesia during labor. Which observation is the most important adverse effect that the practical nurse (PN) should assess for following the administration of the epidural?
Maternal hypotension.
A vaginal hematoma.
A continuous headache.
Urinary retention.
The Correct Answer is A
A. Maternal hypotension is a significant adverse effect of epidural anesthesia that can lead to decreased uterine blood flow and fetal distress. Monitoring for hypotension is critical to ensure both maternal and fetal well-being.
B. While a vaginal hematoma is a potential complication, it is less immediately associated with the administration of epidural anesthesia compared to hypotension.
C. A continuous headache could indicate post-dural puncture but is less common and not the primary immediate concern compared to hypotension following an epidural.
D. Urinary retention can occur with epidural anesthesia, but maternal hypotension is a more urgent and significant immediate concern.
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Related Questions
Correct Answer is D
Explanation
A. Administering cholera vaccines can help prevent further cases but is not the immediate priority for those already infected.
B. Administering prophylactic antibiotics is important but not the highest priority compared to addressing the acute symptoms of cholera.
C. Isolating all infectious diarrhea victims helps prevent the spread of infection but does not address the immediate life-threatening dehydration and electrolyte imbalance.
D. Providing fluid and electrolyte replacement is the highest priority as cholera causes severe dehydration and electrolyte imbalance, which can be fatal if not treated promptly. Immediate rehydration is crucial to save lives.
Correct Answer is B
Explanation
A. Re-assessing the client’s temperature is important but not the priority action since the client is currently afebrile and the cough with yellow sputum could indicate an infection or other condition needing immediate attention.
B. Notifying the charge nurse of the assessment findings is the priority because the yellow-tinged sputum in a client receiving chemotherapy might indicate an infection or complication that requires further investigation and possible intervention.
C. Measuring and recording intake and output is important for overall fluid balance but does not address the immediate concern of a productive cough with potential infection.
D. Providing regular oral hygiene is part of general care but does not address the potential underlying cause of the productive cough and yellow-tinged sputum.
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