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 D

Explanation

A. "You cannot have an amniocentesis until you are at least 35 years of age": This statement is not accurate. While advanced maternal age (35 years or older) is often a factor considered for offering amniocentesis due to the increased risk of chromosomal abnormalities, it is not the only factor. Amniocentesis may be recommended for various medical reasons, such as a history of genetic disorders or abnormal prenatal screening results.

B. "We can schedule the procedure for later today if you'd like": The decision to undergo amniocentesis should not be made lightly, and it is typically based on medical indications or concerns. Immediate scheduling without a medical reason is not appropriate. Informed consent and discussion with the healthcare provider about the risks and benefits of the procedure are essential.

C. "Your provider will schedule a chorionic villus sampling to determine the sex of your baby": Chorionic villus sampling (CVS) is a different prenatal diagnostic procedure used to obtain a small sample of placental tissue for genetic testing. It is not typically used solely for determining the sex of the baby. Amniocentesis is the procedure commonly used for both genetic testing and determining the sex of the fetus.

D. "This procedure determines if your baby has genetic or congenital disorders": This is the most appropriate response. Amniocentesis is a diagnostic procedure that involves the removal of a small amount of amniotic fluid for analysis. It is commonly used to assess the risk of genetic and congenital disorders, including chromosomal abnormalities.

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

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