A nurse is 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?

Hypotension.

Polyuria.

Fetal heart rate 152/min.

Maternal temperature of 37.4° C (99.4° F).

Answer and Explanation

The Correct Answer is A

Choice A rationale:
Hypotension is a common adverse effect of epidural analgesia due to the blockage of sympathetic nerve fibers, which can lead to vasodilation and decreased cardiac output.
Choice B rationale:
Polyuria is not typically associated with epidural analgesia. It could be related to other factors such as fluid administration or underlying medical conditions.
Choice C rationale:
A fetal heart rate of 152/min is within the normal range (110-160 beats/min) and is not an adverse effect of epidural analgesia.
Choice D rationale:
A maternal temperature of 37.4° C (99.4° F) is within the normal range (36.1° C to 37.2° C or 97° F to 99° F) and is not an adverse effect of epidural analgesia.

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Correct Answer is A

Explanation

Choice A rationale:
Urinating 30 mL/hr is correct. This is within the normal urinary output range of 30 to 60 mL/hr, indicating effective voiding.
Choice B rationale:
Not feeling the urge to urinate is incorrect. This could indicate urinary retention, not effective voiding.
Choice C rationale:
A uterine fundus 2 cm above the umbilicus is incorrect. This is unrelated to the client’s ability to void effectively.
Choice D rationale:
A distended bladder upon palpation is incorrect. This could suggest urinary retention, not effective voiding.

A. Human papillomavirus. B. Rubella. C. Tetanus. D. Varicella.

Correct Answer is C

Explanation

Choice A rationale:
Human papillomavirus vaccine is not typically administered during pregnancy.
Choice B rationale:
Rubella vaccine is a live vaccine and is generally contraindicated during pregnancy.
Choice C rationale:
Tetanus vaccine is safe and recommended during pregnancy.
Choice D rationale:
Varicella is a live vaccine and is generally contraindicated during pregnancy.

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A nurse is 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

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