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 A
Explanation
A. Oxycodone, like other opioid medications, can cause constipation, so advising the client to take a stool softener can help prevent or alleviate this common side effect.
B. Urinary frequency is not a common side effect of oxycodone.
C. There is no known association between oxycodone and sunlight exposure, so advising the client to minimize sunlight exposure is unnecessary.
D. Oxycodone can be taken with or without food, so there is no requirement to take it on an empty stomach.
Correct Answer is A
Explanation
A. "This medication can cause an increase in appetite." is correct. Amitriptyline is a tricyclic antidepressant (TCA) that commonly causes increased appetite and weight gain as side effects. Clients should be informed of this possibility and encouraged to monitor their diet and weight while taking the medication.
B. "You might experience hair loss while taking this medication." is incorrect. Hair loss is not a common adverse effect of amitriptyline. This side effect is more commonly associated with other medications, such as chemotherapy agents or certain anticonvulsants.
C. "This medication can cause diarrhea." is incorrect. Amitriptyline typically causes constipation rather than diarrhea due to its anticholinergic effects, which slow gastrointestinal motility. Clients should be advised to increase fiber and fluid intake to help manage constipation.
D.While trouble urinating can occur due to anticholinergic effects, urinary frequency is not a commonly reported adverse effect of amitriptyline.
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