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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While blunt force trauma can cause placental abruption, it is not the most common risk factor. Trauma can lead to abruptio placentae, but this is more likely in cases of severe injury.
Choice B rationale
Cigarette smoking is a risk factor for many pregnancy complications, including placental abruption. However, it is not the most common risk factor.
Choice C rationale
Cocaine use can cause abrupt vasoconstriction and is a risk factor for placental abruption. However, it is not the most common risk factor.
Choice D rationale
Hypertension is the most common risk factor for placental abruption. Chronic hypertension, gestational hypertension, and preeclampsia can all contribute to the risk of developing this condition.
Correct Answer is C
Explanation
Choice A rationale
Betamethasone does not increase the fetal heart rate. It is a corticosteroid given to pregnant women who are at risk of preterm delivery to enhance fetal lung maturity and prevent respiratory distress syndrome.
Choice B rationale
Betamethasone is not used to stop preterm labor contractions. Other medications, such as tocolytics, are used for this purpose.
Choice C rationale
This is the correct answer. Betamethasone is given to promote fetal lung maturity. It is usually given in two doses, 24 hours apart, and takes effect within 24 hours of administration.
Choice D rationale
Betamethasone does not halt cervical dilation. It is given to enhance fetal lung maturity, not to stop labor.
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