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 C
Explanation
A. This statement is incorrect. While it’s essential not to exceed the recommended dose, the
maximum daily limit for nicotine gum is 24 pieces, not 40. Using more than the recommended amount can lead to adverse effects
B. This information is not accurate. Nicotine gum is typically used for a shorter duration. The
treatment plan varies, but it’s essential to follow the recommended dosing and gradually reduce usage over time. The goal is to quit smoking successfully, not to use the gum for 9 months
C. This advice is correct. Nicotine gum is not used like ordinary chewing gum. You should chew it a few times and then “park” it between your cheek and the space below your teeth. The nicotine is absorbed mostly in your mouth. Chewing it slowly over 30 minutes allows for
effective absorption and helps control withdrawal symptoms
D. Drinking water before chewing nicotine gum is not a necessary instruction for its use.
Correct Answer is A
Explanation
A. Bradycardia: Amiodarone, an antiarrhythmic medication, can cause bradycardia as an adverse effect due to its negative chronotropic effects on the heart's electrical conduction system. Bradycardia is a common adverse effect of amiodarone and requires monitoring during therapy.
B. Fever: Fever is not a typical adverse effect of amiodarone. If a client develops a fever while taking amiodarone, other potential causes should be investigated.
C. Hypertension: Hypertension is not a typical adverse effect of amiodarone. Amiodarone is more commonly associated with bradycardia and hypotension.
D. Bradypnea: Bradypnea, or slow respiratory rate, is not a typical adverse effect of amiodarone.
Respiratory adverse effects of amiodarone are more commonly related to pulmonary toxicity, such as pulmonary fibrosis or pneumonitis.
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