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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale

Swaddling a newborn can provide comfort and help soothe them. However, it is not a specific treatment for a Neonatal Abstinence Scoring System (NAS) score of 201.

Choice B rationale

Naloxone is an opioid antagonist used to reverse the effects of opioid overdose. It is not typically administered for NAS unless the newborn is experiencing life-threatening respiratory depression due to opioid exposure. Moreover, it is not specifically indicated for NAS scores greater than 241.

Choice C rationale

Continuing NAS scoring as prescribed is important for monitoring the newborn’s condition. However, a score of 20 indicates significant withdrawal symptoms, which may require more than just monitoring.

Choice D rationale

Administering oral morphine is a common treatment for NAS. Morphine, an opioid medication, is used to manage withdrawal symptoms in newborns with NAS. The goal is to control symptoms and then gradually wean the newborn off the medication.

A. The fetus is likely to have a congenital anomaly, be growth restricted, or demonstrate fetal distress during labor. B. The client is carrying more than one fetus. C. An excessive amount of amniotic fluid is present. D. There is an elevated level of alpha-fetoprotein (AFP) in the amniotic fluid.

Correct Answer is C

Explanation

Choice A rationale

While congenital anomalies, growth restriction, and fetal distress during labor can occur in pregnancies, they are not directly associated with polyhydramnios. Polyhydramnios is a condition characterized by an excessive accumulation of amniotic fluid in the uterus during pregnancy.

Choice B rationale

Carrying more than one fetus can lead to a condition known as twin-to-twin transfusion syndrome, which can result in polyhydramnios in one twin and oligohydramnios in the other. However, carrying more than one fetus does not directly mean the mother will experience polyhydramnios.

Choice C rationale

Polyhydramnios is indeed characterized by an excessive amount of amniotic fluid present in the uterus during pregnancy. This can be due to various reasons such as fetal abnormalities, maternal diabetes, and others.

Choice D rationale

An elevated level of alpha-fetoprotein (AFP) in the amniotic fluid can be an indication of certain fetal abnormalities, but it is not a direct indicator of polyhydramnios.

View Question and Answer

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

A nurse is attending to a client who is receiving opioid epidural analgesia during labor. Which of the following observations should the nurse prioritize?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn who is 72 hours old. The newborn has a Neonatal Abstinence Scoring System (NAS) score of 20. The nurse is planning to contact the provider regarding the newborn’s status.Which of the following prescriptions should the nurse anticipate?

Correct Answer is D

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. What does this diagnosis mean?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A nurse in a provider’s office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. What is the most common risk factor for abruption?

A nurse is caring for a patient who experienced a vaginal birth 3 hours ago. Upon palpation, the fundus is displaced to the right of the midline, is firm, and is two fingerbreadths above the umbilicus. What actions should the nurse complete at this time?

A nurse in an antepartum clinic is caring for a client who is pregnant. Select the assessment findings the nurse should report to the provider.

A nurse is admitting an 8-hour-old, term newborn following a cesarean birth. The nurse observes that the newborn’s skin is yellow. This finding indicates the newborn is experiencing a complication related to which of the following?

A nurse is providing care for a patient who is in labor. After reviewing the patient’s medical history, vital signs, nurse’s notes, and diagnostic results, which of the following complications should the nurse identify that the patient is at risk of developing?

A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this diagnosis?

A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client’s blood work, the nurse notices she does not have immunity to rubella. When should the nurse understand is the recommended time for rubella immunization?

A nurse is caring for a client who gave birth 2 hours ago. The nurse notes that the client’s blood pressure is 60/50 mm Hg. What should be the nurse’s first action?