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 B

Explanation

A. Give oxytocin 20 units IV bolus: Oxytocin is a medication used to induce or augment labor, and it is not the appropriate intervention for a client with placenta previa and significant vaginal bleeding. The priority in this situation is to assess and manage the bleeding.

B. Obtain serial hemoglobin and hematocrit: This is the correct action. Placenta previa can lead to significant bleeding, and obtaining serial hemoglobin and hematocrit levels will help monitor the extent of blood loss and guide decisions regarding transfusions or other interventions.

C. Perform a fundal massage: Fundal massage is not the appropriate intervention for placenta previa. In cases of placenta previa, the placenta is covering or near the cervical os, and vigorous fundal massage can worsen bleeding.

D. Assess for abdominal tenderness: While assessing for abdominal tenderness is important in the overall assessment of a pregnant client, in the context of active bleeding with placenta previa, the immediate focus should be on assessing the extent of bleeding and the client's hemodynamic status.

A. Painful intercourse B. Vaginal itching C. Persistent headaches D. Breast tenderness

Correct Answer is C

Explanation

A. Painful intercourse: Painful intercourse can have various causes, but it is not typically associated with serious complications related to oral contraceptives. It may be addressed with the healthcare provider during a routine follow-up.

B. Vaginal itching: Vaginal itching may be due to various reasons, including infections, but it is not typically a direct side effect of oral contraceptives. However, if the itching is persistent or severe, the client should report it to the provider for appropriate evaluation.

C. Persistent headaches: Persistent headaches can be a concerning side effect associated with the use of oral contraceptives. It may indicate an increased risk of vascular events, such as stroke or thrombosis. Clients experiencing persistent headaches while on oral contraceptives should report this symptom to the healthcare provider immediately for further evaluation.

D. Breast tenderness: Breast tenderness is a common side effect of hormonal contraceptives, and it is not typically an emergency or a sign of serious complications. However, if the breast tenderness is severe or associated with other concerning symptoms, the client should contact the provider for guidance.

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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

A nurse is caring for a client who is at 32 weeks of gestation and has placenta previa. The client is exhibiting a large amount of vaginal bleeding. Which of the fallowing actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who is taking an oral contraceptive. The nurse should instruct the client to report which of the following findings to the provider immediately?

Correct Answer is C

Explanation

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