A nurse is assessing a client who is in active labor and just received an epidural. Which of the following findings should the nurse document as an adverse effect?

Tachypnea

Hyperreflexia

Hypothermia

Hypotension

Answer and Explanation

The Correct Answer is D

Rationale:

A. Tachypnea: An increased respiratory rate is not commonly associated with epidural anesthesia and is not a typical adverse effect. It may result from anxiety or pain but does not directly indicate a problem with the epidural.

B. Hyperreflexia: Epidurals often reduce sensation and reflexes, not heighten them. Hyperreflexia is not expected and would not be a direct adverse effect of epidural administration during labor.

C. Hypothermia: While mild temperature changes may occur, hypothermia is not a common or significant adverse effect of epidural anesthesia. It is not typically monitored as a key complication.

D. Hypotension: Epidural anesthesia can cause vasodilation by blocking sympathetic nerve fibers, leading to a drop in maternal blood pressure. This is a well-known and common adverse effect requiring close monitoring and potential intervention.

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Correct Answer is A

Explanation

Rationale:

A. Limited hip abduction: Limited abduction of the hips in a 1-month-old can indicate developmental dysplasia of the hip (DDH). This finding warrants further evaluation, such as ultrasound imaging, to rule out structural abnormalities and initiate early treatment if needed.

B. Equal leg length: Equal leg length is a normal finding and does not require intervention. Leg length discrepancies are more concerning and often associated with hip dislocation or other musculoskeletal conditions.

C. Symmetric gluteal and thigh skin folds: Symmetry in the gluteal and thigh folds is a reassuring sign that typically rules out DDH. Asymmetry would be more suggestive of a hip abnormality requiring follow-up.

D. Femoral head remains in the acetabulum during the Barlow maneuver: This is a normal finding. The Barlow test assesses for hip instability, and if the femoral head remains stable within the socket, no further evaluation is needed.

A. Self-mutilation B. Social isolation C. Paranoid ideation D. Lack of empathy

Correct Answer is D

Explanation

Rationale:

A. Self-mutilation: This behavior is more commonly associated with borderline personality disorder. Individuals with borderline traits may engage in self-harm as a means of emotional regulation or response to abandonment fears, not typical in antisocial personality disorder.

B. Social isolation: Clients with antisocial personality disorder are often socially manipulative and may actively engage with others for personal gain. They are typically not socially withdrawn but can be superficially charming and exploitative.

C. Paranoid ideation: Paranoia is more closely linked with paranoid or schizotypal personality disorders. While someone with antisocial traits may be suspicious if it serves their manipulative purposes, persistent paranoid ideation is not a defining feature.

D. Lack of empathy: A hallmark feature of antisocial personality disorder is a disregard for others' feelings, rights, and safety. These clients often exhibit a lack of remorse and empathy, making them prone to violating social norms and laws without guilt.

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A nurse is assessing a client who is in active labor and just received an epidural. Which of the following findings should the nurse document as an adverse effect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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