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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Constipation: Constipation is not a commonly reported adverse effect of clopidogrel.
Therefore, it is not necessary to instruct the client to monitor and report constipation as an adverse effect.
B. Weight loss: Weight loss is not a commonly reported adverse effect of clopidogrel. Therefore, it is not necessary to instruct the client to monitor and report weight loss as an adverse effect.
C. Bruising: Clopidogrel is an antiplatelet medication that inhibits platelet aggregation.
Therefore, one of the potential adverse effects is an increased risk of bleeding, which can
manifest as easy bruising or prolonged bleeding from minor injuries. Instructing the client to monitor and report bruising is important for early detection of bleeding complications.
D. Blurred vision: Blurred vision is not a commonly reported adverse effect of clopidogrel.
Therefore, it is not necessary to instruct the client to monitor and report blurred vision as an adverse effect.
Correct Answer is D
Explanation
A. Oxycodone primarily exerts its analgesic effects through binding to opioid receptors and modulating neurotransmitter release, rather than blocking sodium channels.
B. Oxycodone does not directly inhibit prostaglandin synthesis; this mechanism is associated with nonsteroidal anti-inflammatory drugs (NSAIDs).
C. Oxycodone does not promote vasodilation of cranial arteries. This mechanism is more commonly associated with medications used to treat migraines, such as triptans.
D. Oxycodone is an opioid analgesic that acts centrally on the nervous system to depress respiratory drive, leading to respiratory depression, especially at higher doses.
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