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. “I should stay upright for at least 15 minutes after taking this medication.": This statement is correct as remianing upright reduces the risk of reflux that is common after taking the medication.
B. “I should take an antacid with this medication to prevent stomach upset.": Antacids can decrease the absorption of iron, so taking them with ferrous gluconate is not recommended.
C. "I should take this medication with 8 ounces of milk.": Milk can inhibit the absorption of iron, so taking ferrous gluconate with milk is not advised. It's better to take it with water or juice.
D. “I should notify my provider if my stools turn black.": This statement is incorrect as black stools are an expected side effect of the medication.
Correct Answer is A
Explanation
A. Hypotension can occur as part of an allergic reaction to ceftriaxone, indicating a severe systemic response.
B. Bradycardia is not typically associated with an allergic reaction to ceftriaxone.
C. Polyuria is excessive urination and is not a common manifestation of an allergic reaction to ceftriaxone.
D. Nausea can occur with ceftriaxone administration but is not specific to an allergic reaction.
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