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. Epicanthal folds: Epicanthal folds are the skin folds of the upper eyelid covering the inner corner of the eye. These folds are a normal anatomical variation and are not typically related to forceps-assisted births.

B. Depressed anterior fontanel: A depressed fontanel (the soft spot on a baby's head) might indicate dehydration or a potential concern but is not directly associated with forceps use during birth.

C. Facial asymmetry

Forceps-assisted births involve the use of forceps to aid in the delivery of the baby's head. Facial asymmetry can occur as a result of the pressure applied by the forceps during the birth process. This pressure might cause temporary facial bruising or swelling, leading to an asymmetrical appearance, particularly in the immediate post-birth assessment.

D. Uneven gluteal skinfolds: Uneven gluteal skinfolds, which refer to asymmetry in the skinfolds of the buttocks, are not typically linked to forceps use during delivery. This finding might be a normal variation or could indicate other unrelated conditions.

A. Protective environment B. Contact C. Droplet D. Airborne

Correct Answer is B

Explanation

. Protective environment: Protective environment precautions are used for clients with compromised immune systems, such as those undergoing stem cell transplantation. This precaution aims to protect the client from exposure to environmental pathogens.

B. Contact: This is the correct answer. Contact Precautions are appropriate for clients with C. difficile infection. The precautions include using gloves and gowns when entering the room and ensuring proper hand hygiene to prevent the transmission of the bacteria.

C. Droplet: Droplet precautions are used for diseases that are transmitted through respiratory droplets, such as influenza or pertussis. C. difficile is not primarily transmitted through respiratory droplets.

D. Airborne: Airborne precautions are used for diseases that can be transmitted by tiny particles suspended in the air, such as tuberculosis or chickenpox. C. difficile is not transmitted through the airborne route.

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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

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