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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Cerebral manifestations such as a mild headache can be a sign of preeclampsia, a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. This should be reported to the provider.
Choice B rationale
Gastrointestinal assessment findings such as heartburn can be common in pregnancy due to hormonal changes and the growing uterus pressing on the stomach. However, severe or persistent heartburn may indicate a more serious condition like gastroesophageal reflux disease (GERD) or preeclampsia. This should be reported to the provider.
Choice C rationale
Respiratory rate alone, without knowing whether it’s increased, decreased, or normal, is not enough information to determine if it should be reported to the provider.
Choice D rationale
Deep tendon reflexes can be hyperactive in clients with preeclampsia. An increase in deep tendon reflexes can be a sign of worsening preeclampsia and should be reported to the provider.
Correct Answer is A
Explanation
Choice A rationale
This is the correct answer. In infants of mothers with poorly controlled diabetes, hyperinsulinemia can lead to increased oxygen consumption and metabolic rate, which can contribute to the development of respiratory distress syndrome.
Choice B rationale
Increased blood viscosity is not the most likely cause of respiratory distress in a macrosomic newborn of a mother with poorly controlled diabetes.
Choice C rationale
A brachial plexus injury is a potential complication of delivery for macrosomic infants, but it is not a cause of respiratory distress syndrome.
Choice D rationale
Increased deposits of fat in the chest and shoulder areas can make delivery more difficult and can increase the risk of birth injuries, but they are not the most likely cause of respiratory distress syndrome in a macrosomic newborn of a mother with poorly controlled diabetes.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.