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. The correct order is
- wipe off tops of insulin vials with alcohol sponge.
- draw back amount of air into the syringe that equals total dose.
- inject air equal to NPH dose into NPH vial. ...
- air equal to regular dose into regular vial.
- invert regular insulin bottle and withdraw regular insulin dose.
- without adding more air into NPH vial, carefully withdraw NPH dose
B. Withdraw the regular insulin from the vial: This step should occur after injecting air into the regular insulin vial. The nurse should draw up the regular insulin before drawing up the NPH
insulin.
C. Inject air into the regular insulin vial: Inject air into the regular insulin vial is not thecorrect first step to avoid contamination of the clear insulin with cloudy insulin..
D. Withdraw the NPH insulin from the vial: This step should occur after withdrawing the regular insulin. The nurse should draw up the NPH insulin after drawing up the regular insulin to ensure the correct sequence and dosage.
Correct Answer is A
Explanation
A. Filing a report with the facility to document the incident as a near miss medication error is essential for tracking and investigating medication errors to prevent future occurrences.
B. While contacting the prescribing provider may be necessary, the priority is to report the error internally within the facility.
C. While documenting the nurse's actions is important, it is essential to report the error through the appropriate channels within the facility.
D. While informing the client about the error is necessary, the immediate action should be to report the error internally within the facility.
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