A nurse is assessing a client who is in labor and is receiving epidural anesthesia. Which of the following findings should the nurse identify as the priority?
Urinary retention
Leg weakness
Hypotension
Temperature 39°C (102.2°F)
The Correct Answer is C
A. Urinary retention: While urinary retention can be a complication of epidural anesthesia, it is not the priority finding in this scenario. The priority is to address potential complications that can lead to maternal or fetal compromise.
B. Leg weakness: Leg weakness can occur as a side effect of epidural anesthesia but is not the priority finding in this scenario unless it is severe and compromises the client's ability to
mobilize or push during labor.
C. Hypotension: Hypotension is a common complication of epidural anesthesia due to sympathetic blockade, which can lead to decreased venous return and subsequent maternal
hypotension. Maternal hypotension can compromise uteroplacental perfusion, leading to fetal distress. Therefore, addressing hypotension promptly is the priority to prevent adverse maternal and fetal outcomes.
D. Temperature 39°C (102.2°F): While fever should be monitored and addressed, it is not the priority finding in this scenario unless it indicates an infection, which would require further assessment and intervention. However, maternal hypotension poses a more immediate risk to both the mother and the fetus during labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["19"]
Explanation
Drip rate (gtt/min) = (Volume to be infused in mL × Drop factor) ÷ Time of infusion in minutes
Given:
Volume to be infused = 350 mL Drop factor = 10 gtt/mL
Time of infusion = 3 hours = 180 minutes
Plugging these values into the formula:
Drip rate = (350 mL × 10 gtt/mL) ÷ 180 min Drip rate ≈ (3500 gtt) ÷ 180 min
Drip rate ≈ 19.4 gtt/min
Rounding to the nearest whole number, the drip rate is approximately 19 gtt/min. Therefore, the nurse should set the manual IV infusion to deliver 19 gtt/min.
Correct Answer is D
Explanation
A. Treatment for active pulmonary tuberculosis typically lasts 6 to 9 months, not 3 years.
B. Monitoring kidney function is not typically required for tuberculosis medication; however, liver function tests may be needed.
C. Tuberculin skin tests are used for diagnosis, not for monitoring treatment progress.
D. Treatment of active pulmonary tuberculosis usually involves a combination of antibiotics, typically two or more medications, to prevent the development of drug-resistant strains.
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