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 C
Explanation
Rationale:
A. Prolonged QT interval: This is not a typical sign of morphine toxicity. QT prolongation is more commonly associated with certain antipsychotics, antiarrhythmics, or methadone, not opioids like morphine.
B. Fluid retention: Morphine does not typically cause fluid retention. While it may contribute to urinary retention, generalized fluid accumulation is not characteristic of opioid toxicity and may point to other causes like heart or renal failure.
C. Bradypnea: Respiratory depression, including bradypnea, is the hallmark sign of opioid toxicity. Morphine suppresses the brainstem’s respiratory centers, reducing respiratory rate and depth, which can become life-threatening without intervention.
D. Hyperactive deep tendon reflexes: Opioids tend to cause central nervous system depression, which would more likely lead to diminished reflexes. Hyperactive reflexes are not associated with morphine toxicity and may suggest a different neurological issue.
Correct Answer is A
Explanation
Rationale:
A. Use a cane for support while walking: A cane can enhance balance and reduce the risk of falls in clients with multiple sclerosis, who may experience muscle weakness, spasticity, or ataxia. It promotes mobility while maintaining safety in the home environment.
B. Avoid the use of orthotics: Orthotic devices, such as ankle-foot orthoses, can actually be helpful in improving gait and preventing foot drop. Advising against their use may deprive the client of important supportive tools.
C. Implement a rigorous range-of-motion exercise plan: While exercise is important, a rigorous plan may lead to fatigue and overheating, which can worsen MS symptoms. A gentle, balanced routine tailored to the client’s tolerance is safer.
D. Walk with feet close together for stability: Keeping the feet close together narrows the base of support and increases fall risk. A wider stance improves balance and stability, which is safer for ambulating clients with MS.
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