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 C
Explanation
A. Subcutaneous in the left vastus lateralis: Phytonadione is usually administered IM, not subcutaneously. The vastus lateralis muscle in the thigh is a common site for IM injections in newborns.
B. IM in the right deltoid: The deltoid muscle in the upper arm is not typically the recommended site for administering medications to newborns. The vastus lateralis muscle in the thigh is preferred for newborn IM injections due to better muscle development and blood flow.
C. IM in the left vastus lateralis: This is the correct option. Phytonadione, or Vitamin K, is routinely given to newborns to prevent vitamin K deficiency bleeding (VKDB). It's administered as an IM injection into the vastus lateralis muscle in the thigh, which is a standard practice for newborn vitamin K administration.
D. Subcutaneous in the right deltoid: Subcutaneous administration in the deltoid is not typically used for newborns, especially for medications like phytonadione that are commonly administered IM.
Correct Answer is C
Explanation
A. Erythema toxicum: Erythema toxicum is a common and benign rash that appears in the first few days of life. It is characterized by pink or red blotches with a small, pimple-like elevation in the center. It is unrelated to a nuchal cord.
B. Periauricular papillomas: Periauricular papillomas are small skin tags or growths around the external ear. They are not typically associated with a nuchal cord and are unrelated to the newborn's delivery.
C. Facial petechiae: A nuchal cord occurs when the umbilical cord is wrapped around the baby's neck. During delivery, this can lead to pressure on the baby's head and face, resulting in small, pinpoint red or purple spots known as petechiae. These are often seen on the face and neck and are considered a transient and benign finding.
D. Telangiectatic nevi: Telangiectatic nevi, also known as "stork bites" or "angel kisses," are common vascular birthmarks. They are not specifically associated with a nuchal cord but rather represent dilated blood vessels near the surface of the skin.
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