A nurse in assessing a client who is in labor and has received epidural analgesia. Which of the following findings should the nurse recognize and document as an adverse effect of epidural analgesia?

Fetal heartrate 152/min

Hypotension

polyuria

Maternal temperature of 37.4 C (99.4 F)

Answer and Explanation

The Correct Answer is B

A. Fetal heart rate 152/min: Fetal heart rate is not typically considered an adverse effect of epidural analgesia. The focus of epidural analgesia is on providing pain relief for the mother rather than directly affecting the fetal heart rate.

B. Hypotension: Hypotension (low blood pressure) is a common adverse effect of epidural analgesia. Epidural anesthesia can cause vasodilation, leading to a decrease in blood pressure. The nurse should monitor the client's blood pressure closely and administer interventions as needed, such as IV fluids or medications to address hypotension.

C. Polyuria: Polyuria (excessive urination) is not a direct adverse effect of epidural analgesia. Epidural analgesia primarily affects pain sensation rather than urinary function.

D. Maternal temperature of 37.4 C (99.4 F): A slightly elevated maternal temperature is not a common adverse effect of epidural analgesia. However, the nurse should monitor for signs of infection or other complications and report any significant temperature changes to the healthcare provider.

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Correct Answer is C

Explanation

A. The client will demonstrate proper bathing of the infant: This goal is more appropriate for later phases of postpartum adjustment when the mother becomes more involved in caring for her infant. During the taking-in phase, the focus is on the mother's own recovery.

B. The client will verbalize appropriate car seat safety: This goal is related to the safety and care of the newborn, and it may be more relevant in the taking-hold phase when the mother becomes more actively involved in caring for her baby.

C. The client will have adequate nutritional intake: This is the correct goal. Adequate nutritional intake is important for the mother's recovery, energy levels, and breastfeeding success. The nurse should assess and promote proper nutrition during the taking-in phase.

D. The client will identify individual family member roles: Family roles and dynamics are more commonly addressed in the postpartum adjustment phase known as the let-go phase, which occurs later as the mother becomes more comfortable and accepting of her new role.

A. Administer 500 ml lactated Ringer's IV bolus B. Replace the surgical dressing C. Apply an ice pack to the incision site D. Evaluate urinary output

Correct Answer is D

Explanation

A. Administer 500 ml lactated Ringer's IV bolus:

This choice may be relevant in the context of postpartum hemorrhage, but the first step should be to assess the client's status, including urinary output. Administering fluids without a clear assessment may not address the underlying cause.

B. Replace the surgical dressing:

Vaginal bleeding after a cesarean birth is unlikely to be addressed by replacing the surgical dressing. This action may not address the root cause of the bleeding, which needs further assessment.

C. Apply an ice pack to the incision site:

Using an ice pack is not the appropriate intervention for postpartum bleeding. Ice is typically used for pain and swelling, not for controlling bleeding.

D. Evaluate urinary output:

This is the correct choice. Evaluating urinary output is crucial to assess the client's overall fluid status and kidney perfusion. In the context of postpartum bleeding, it helps determine if there is hypovolemia or other issues contributing to the bleeding. Adequate urinary output is a positive sign of organ perfusion.

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A nurse in assessing a client who is in labor and has received epidural analgesia. Which of the following findings should the nurse recognize and document as an adverse effect of epidural analgesia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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