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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. "You are feeling anxious now; why don't you give it some time before making a final decision?": This minimizes the client’s current emotional distress and does not address the seriousness of the statement. It may come across as dismissive rather than therapeutic.
B. "You should talk with your family members before making this decision.": Although involving family in major decisions can be helpful, the focus should be on the client's feelings and wishes first.
C. "I will discuss this with your primary health care provider, and we can discuss this more tomorrow.": Deferring the conversation may delay support for someone expressing emotional exhaustion and possible suicidal ideation. Prompt intervention is essential in these situations.
D. "Let me refer you to talk to someone regarding your treatment options.": This response acknowledges the client's emotional state while also offering a supportive and appropriate next step. It opens access to counseling or mental health services and helps the client explore options without judgment.
Correct Answer is C
Explanation
Rationale:
A. Instruct the parent to give 5 mcg of vitamin D daily: While vitamin D supplementation is recommended for breastfed infants, this advice does not address the inappropriate introduction of cow’s milk, which can cause complications such as intestinal bleeding and iron deficiency in infants under 12 months.
B. Instruct the parent to give the infant water every 3 hr between feedings: Offering water to infants under 6 months is discouraged, as it can displace essential nutrients from breast milk or formula and increase the risk of water intoxication due to immature kidneys.
C. Advise the parent to avoid giving cow's milk to the infant prior to 1 year of age: Cow's milk is not suitable for infants under 12 months because it lacks adequate iron and nutrients, and its high protein content can irritate the immature kidneys and intestinal lining.
D. Recommend the parent mix the milk with rice cereal for feedings: Mixing cow’s milk with cereal does not resolve its nutritional inadequacy or potential risks. Introducing solids and allergenic foods should follow developmental readiness and established pediatric guidelines.
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