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)
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hot flashes: Hot flashes are not a typical adverse effect of terbutaline. Hot flashes are more commonly associated with hormonal changes, such as those that occur during menopause.
B. Heart palpitations: This is the correct answer. Terbutaline can stimulate beta-2 receptors in the heart, leading to increased heart rate and palpitations. Clients receiving terbutaline should be monitored for cardiac side effects.
C. Shortness of breath: While terbutaline is used to relax smooth muscles, it can also affect beta-2 receptors in the respiratory system. However, shortness of breath is not a common adverse effect and may indicate other respiratory issues.
D. Bradycardia: Bradycardia, or a slow heart rate, is not a typical adverse effect of terbutaline. The medication is more likely to increase heart rate due to its beta-2 adrenergic agonist properties.
Correct Answer is D
Explanation
A. Report of perineal pain as 0 on a scale of 0 to 10: Perineal pain is more directly related to the effects of spinal anesthesia rather than fluid status. A decrease in perineal pain would be expected after the administration of spinal anesthesia, but it may not specifically indicate the effectiveness of the IV bolus.
B. Report of relief of pruritus: Pruritus (itching) is a common side effect of spinal anesthesia. Relief of pruritus can be expected after the administration of spinal anesthesia, but it is not a direct indicator of the effectiveness of the IV bolus.
C. Increased urinary output: Increased urinary output may indicate improved renal perfusion or fluid balance but is not a specific indicator of the effectiveness of the IV bolus in the context of spinal anesthesia for labor.
D. Blood pressure 110/70 mm Hg: This is the correct answer. Blood pressure is an important parameter to monitor, especially after administering an IV bolus of fluids. A blood pressure within the normal range (110/70 mm Hg) suggests that the bolus has been effective in addressing any hypovolemia or dehydration.
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