A nurse is caring for a client who is receiving an epidural for continuous labor analgesia.
Which of the following findings should indicate to the nurse that the treatment is effective?
The client reports slight pressure with contractions.
The client has bladder distention.
The client's systolic blood pressure decreases by 20 mm Hg.
The client is unable to move their legs or feet.
The Correct Answer is A
Choice A rationale
The primary goal of epidural analgesia is to provide effective pain relief while allowing the client to maintain some sensation, particularly pressure, which indicates the epidural is blocking nociceptive pain signals effectively without completely eliminating proprioceptive awareness. This selective blockade allows the client to feel contractions, facilitating pushing efforts, while minimizing pain perception by blocking transmission of pain impulses via spinal nerves.
Choice B rationale
Bladder distention is a common side effect of epidural analgesia, resulting from the blockade of parasympathetic nerve fibers innervating the bladder, which can impair the micturition reflex. While it indicates the epidural's systemic effect, it is an adverse effect requiring intervention, such as catheterization, rather than a direct indicator of effective pain management.
Choice C rationale
A decrease in systolic blood pressure by 20 mm Hg, or more, is a common adverse effect of epidural analgesia, caused by sympathetic blockade, leading to vasodilation and subsequent peripheral pooling of blood. While it demonstrates the systemic absorption and action of the anesthetic, it signifies a complication requiring management, not an indicator of effective pain relief for labor.
Choice D rationale
Inability to move legs or feet suggests a dense motor blockade, which can occur with epidural analgesia but is not the desired outcome for labor. While a degree of motor weakness may be present, complete motor paralysis can hinder effective pushing during the second stage of labor and is usually avoided to allow for maternal participation in the birth process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A,B,C,D
Explanation
Observe the newborn's respirations. Auscultate the newborn's heart rate. Auscultate newborn's abdomen. Test the newborn's reflexes.
Correct Answer is C
Explanation
Choice A rationale
Applying ice packs aligns with Western medical practices for reducing swelling and pain. However, traditional yin and yang beliefs often emphasize warmth during the postpartum period to restore a perceived loss of "hot" energy after childbirth. Cold applications could be seen as counterproductive to this balance.
Choice B rationale
Maintaining a cool environment would contradict the traditional belief in maintaining warmth for the postpartum client. In many cultures, a "hot-cold" theory dictates that the postpartum period is a "cold" state, requiring warmth to restore balance and prevent illness. A cool room would be perceived as harmful.
Choice C rationale
Providing a warm beverage aligns with traditional yin and yang postpartum care. Childbirth is often seen as a significant loss of "yang" energy (warmth, activity). Consuming warm foods and beverages helps to replenish this energy, promoting restoration of balance and preventing "cold" illnesses according to this belief system.
Choice D rationale
Showering twice daily, especially with cool water, might conflict with traditional postpartum practices that often restrict bathing or emphasize warm baths. The concern is often about preventing "cold" from entering the body and disrupting the balance, as well as conserving energy during a vulnerable period.
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