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 ["1.5"]
Explanation
Convert the client's weight from pounds to kilograms by dividing by 2.2. 198 lb / 2.2 = 90 kg
Calculate the dose of filgrastim in micrograms by multiplying the client's weight in kilograms by the prescribed dose per kilogram. 90 kg x 5 mcg/kg = 450 mcg
Calculate the volume of filgrastim in milliliters by dividing the dose in micrograms by the concentration of the available solution. 450 mcg / 300 mcg/mL = 1.5 mL
Round the answer to the nearest tenth. The nurse should plan to give 1.5 mL of filgrastim with each dose.
Correct Answer is C
Explanation
A. Amphotericin B lipid complex naturally appears as an opaque, yellow to amber colored suspension. Discarding the medication because it is yellow is incorrect, as this is its expected normal appearance.
B. Amphotericin B lipid complex is highly incompatible with saline solutions and will precipitate if it comes into contact with them. The IV tubing must be primed and flushed strictly with 5% Dextrose in Water (D5W), not 0.9% sodium chloride.
C. The standard recommended administration protocol for amphotericin B lipid complex is to deliver the intravenous infusion at a rate of 2.5 mg/kg/hour, which typically translates to an overall infusion duration of approximately 2 hours.
D. To avoid accidental rapid infusion, which can induce severe adverse effects such as acute hypotension, cardiac arrhythmias, and cardiopulmonary arrest, amphotericin B must always be regulated by an electronic infusion pump rather than a manual gravity flow set.
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