A nurse is assessing a client in labor who has had epidural esthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?
Hypotension
Respiratory depression
Tachycardia
Vomiting
The Correct Answer is A
A. Hypotension: This is the correct answer. Hypotension, or low blood pressure, is a common side effect of epidural anesthesia. The epidural can block sympathetic nerves, which can cause blood vessels to dilate and lead to a drop in blood pressure.
B. Respiratory depression: While respiratory depression can occur with certain types of anesthesia, it is not a common side effect of epidural anesthesia.
C. Tachycardia: Tachycardia, or rapid heart rate, is not a typical side effect of epidural anesthesia.
D. Vomiting: Nausea and vomiting can occur with any type of anesthesia, but they are not specific to epidural anesthesia and are not the most common complication. Hypotension is a more common and significant complication that should be monitored for in a client who has had an epidural block.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Headache for 30 min: While a headache can be a side effect of magnesium sulfate, it is not typically a critical concern that needs to be reported immediately. However, persistent or severe headaches should be reported.
B. Fetal heart rate 158/min: This is within the normal range for a fetal heart rate (110-160 beats per minute), so it would not typically need to be reported.
C. Respirations 16/min: This is within the normal range for adult respiratory rate (12-20 breaths per minute), so it would not typically need to be reported.
D. Urinary output 40 mL in 2 hours: This is the correct answer. A urinary output of less than 30 mL/hr. may indicate renal insufficiency, which can be a serious side effect of magnesium sulfate therapy. This should be reported to the provider immediately.
Correct Answer is D
Explanation
A. Evaluate client for the presence of chills and increased uterine tenderness using palpation: While this is an important assessment, it is not the priority following an amniotomy. The priority is to assess the well-being of the fetus, which is done by assessing the fetal heart rate pattern.
B. Observe color and consistency of fluid: Observing the color and consistency of the amniotic fluid is important to identify potential complications such as meconium-stained amniotic fluid. However, the priority is to assess the fetal heart rate pattern to ensure fetal well-being.
C. Assess the client’s temperature: While monitoring the client’s temperature is important to identify potential infection, the priority following an amniotomy is to assess the fetal heart rate pattern.
D. Assess the fetal heart rate pattern: This is the correct choice. The priority nursing action following an amniotomy is to assess the fetal heart rate pattern. This is done to ensure fetal well-being, as complications such as cord prolapse can occur following an amniotomy, which would be indicated by changes in the fetal heart rate pattern. If cord prolapse is suspected, emergency measures would need to be taken. Therefore, assessing the fetal heart rate pattern is the priority nursing action.
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