A nurse is attending to a client who is receiving opioid epidural analgesia during labor. Which of the following observations should the nurse prioritize?
The client reports profuse itching.
Temperature 38.2°C (100.8°F).
Blood pressure 80/56 mm Hg.
The client reports weakness of the lower extremities.
The Correct Answer is C
Choice A rationale
While itching can be a side effect of opioid analgesics, it is not the priority observation. Itching can be uncomfortable for the client, but it is not life-threatening.
Choice B rationale
A temperature of 38.2°C (100.8°F) indicates a low-grade fever. While this should be monitored, it is not the priority observation in this situation.
Choice C rationale
The priority observation is the client’s blood pressure. Opioid epidural analgesia can cause hypotension, which can lead to inadequate perfusion to the mother and the fetus. Therefore, the nurse should prioritize monitoring the client’s blood pressure.
Choice D rationale
Weakness of the lower extremities can be a side effect of epidural analgesia, but it is not the priority observation. The nurse should monitor for this, but it is not as critical as monitoring the client’s blood pressure.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Administering Vitamin K is an important step in newborn care as it helps with blood clotting and prevents a rare but serious bleeding disorder called Vitamin K Deficiency Bleeding.
However, it is not the immediate priority after ensuring a patent airway.
Choice B rationale
Administering eye prophylaxis, typically in the form of antibiotic ointment, is a standard procedure in newborn care to prevent neonatal conjunctivitis. However, this is not the immediate priority after ensuring a patent airway.
Choice C rationale
Placing an identification bracelet on the newborn is crucial for ensuring the baby’s safety and preventing mix-ups. However, this is not the immediate priority after ensuring a patent airway.
Choice D rationale
Drying the skin of the newborn is the priority action after ensuring a patent airway. This is because newborns are wet with amniotic fluid at birth, and they can lose heat quickly through evaporation if not dried immediately. This can lead to hypothermia, which can be dangerous for the newborn.
Correct Answer is A
Explanation
Choice A rationale
Regular physical activity plays a key role in managing gestational diabetes. The American College of Obstetricians and Gynecologists (ACOG) recommends aiming for 150 minutes of moderate-level exercise each week during pregnancy. Reducing the exercise schedule to 3 days a week may not provide the recommended amount of physical activity needed to manage gestational diabetes effectively.
Choice B rationale
Glyburide is an oral medication that can be used to manage gestational diabetes when diet and exercise are not enough. It is usually taken before breakfast or the first main meal of the day.
Choice C rationale
This statement is correct. Women who have had gestational diabetes have an increased risk of developing type 2 diabetes later in life.
Choice D rationale
This statement is correct. A diet that includes about 40% to 45% carbohydrates is recommended for managing gestational diabetes.
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