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. “I can cut the patches in half to save money": Cutting nitroglycerin patches is not recommended as it can alter the medication's release rate and efficacy. Therefore, this statement indicates a misunderstanding and should be corrected.
B. “I will apply a new patch to the same site whenever I replace it": Rotating patch sites is essential to prevent skin irritation and tolerance development. Therefore, this statement indicates a misunderstanding and should be corrected.
C. “I will take the patch off after dinner every night": This statement demonstrates understanding because nitroglycerin patches are typically worn for a certain number of hours (e.g., 12-14 hours) and then removed for a drug-free interval to prevent tolerance development.
D. "I can put a second patch on if I have chest pain": Applying multiple nitroglycerin patches simultaneously can lead to excessive vasodilation and hypotension, which can be dangerous. Therefore, this statement indicates a misunderstanding and should be corrected.
Correct Answer is C
Explanation
A. Hypomagnesemia: While lithium can affect magnesium levels, starting a new exercise program is not typically associated with hypomagnesemia. Hypomagnesemia may result in muscle weakness, tremors, and cardiac dysrhythmias.
B. Hypocalcemia: Starting a new exercise program is not typically associated with hypocalcemia. Hypocalcemia may present with muscle cramps, tetany, and seizures.
C. Hyponatremia: Starting a new exercise program may lead to dehydration and electrolyte imbalances, including hyponatremia (low sodium levels). This can have profound effects on patients taking lithium. Symptoms of hyponatremia include weakness, confusion, and seizures.
D. Hypokalemia is not a common occurrence among individuals doing exercise.
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