A nurse is caring for a 26-year-old female client who is in active labor in the labor and delivery unit.
The client has requested epidural anesthesia, and it has been administered to manage her pain during labor. The nurse is now monitoring her condition closely.
Fetal decelerations
Reports of pain
Nausea
Dizziness
Hypotension
Difficulty breathing
Correct Answer : A,E,F
Choice A rationale: Fetal decelerations require immediate action because they indicate potential fetal distress. Continuous fetal monitoring is essential to assess the fetus's well-being, and any signs of distress must be addressed promptly to ensure a safe delivery.
Choice E rationale: Hypotension is a common side effect of epidural anesthesia and can lead to decreased blood flow to the fetus. Immediate intervention, such as administering IV fluids or medications, is necessary to stabilize the mother's blood pressure and ensure adequate fetal perfusion.
Choice F rationale: Difficulty breathing is a critical sign that may indicate a severe reaction to the epidural anesthesia or other complications. Immediate assessment and intervention are required to ensure the mother's respiratory status is stable and to address any underlying issues.
Choice B rationale: Reports of pain, while important, do not require immediate emergency action compared to the other findings. Pain management should be adjusted accordingly, but it does not pose an immediate threat to the mother or fetus.
Choice C rationale: Nausea, while uncomfortable, is a common side effect of epidural anesthesia and does not require immediate emergency intervention. It can be managed with antiemetic medications.
Choice D rationale: Dizziness can be a side effect of epidural anesthesia or hypotension, but it is not as critical as the other findings that require immediate emergency attention. It should be monitored and addressed as part of overall care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1000"]
Explanation
Step 1 is 500 mL ÷ 30 min.
Step 2 is 16.67 mL/min × 60 min/hour. Answer: 1000 mL/hour.
Correct Answer is C
Explanation
Choice A rationale
Pedal edema is an assessment related to heart failure or peripheral vascular disease but is not specifically connected to the adverse effects of prasugrel, which is an antiplatelet medication that primarily affects blood clotting processes.
Choice B rationale
Measuring body temperature can help detect infections or fever, but it is not a primary assessment for the adverse effects of prasugrel. The medication's adverse effects are more closely related to bleeding risks.
Choice C rationale
Prasugrel, an antiplatelet medication, increases the risk of bleeding. Observing the color of urine can help detect hematuria, an indication of internal bleeding, making it a critical assessment for clients taking this medication.
Choice D rationale
Assessing skin turgor is generally used to evaluate hydration status, not to monitor for adverse effects of prasugrel. This assessment would not provide relevant information about bleeding risks associated with prasugrel use.
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