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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
900 mL of urine output since birth (9 hours postpartum) translates to an average of 100 mL/hour. A normal urine output is typically 0.5 to 1 mL/kg/hour, which is usually greater than 30 mL/hour for adults. This indicates adequate renal perfusion and fluid balance rather than deficit.
Choice B rationale
A temperature of 37.6° C (99.6° F) is considered a low-grade fever. While it could be an early sign of infection, it is not a direct indicator of fluid volume deficit. Normal postpartum temperature may slightly increase due to dehydration or exertion during labor but usually remains below 38°C (100.4°F).
Choice C rationale
Reports of excessive sweating could be a compensatory mechanism for fever or a response to hormonal changes postpartum, but it is not a primary indicator of fluid volume deficit. In fact, excessive sweating can contribute to fluid loss, but it is not the most definitive sign.
Choice D rationale
A blood pressure of 80/55 mm Hg, particularly with a quantitative blood loss of 1200 mL, is a significant indicator of fluid volume deficit, specifically hypovolemic shock. Normal postpartum blood pressure is usually similar to pre-pregnancy levels (e.g., 90/60 to 120/80 mmHg). The low blood pressure reflects inadequate circulatory volume compromising tissue perfusion.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A rationale: Calcium gluconate is the antidote for magnesium sulfate toxicity, often used in labor inductions complicated by preeclampsia or gestational hypertension. Having it readily available ensures prompt treatment of symptoms like respiratory depression or cardiac arrhythmias caused by magnesium overdose. This safety measure is critical because oxytocin use can increase uterine contractions and magnesium sulfate use requires close monitoring to prevent toxicity.
Choice B rationale: Obtaining the client’s heart rate prior to initiating oxytocin is essential to establish a baseline and monitor for tachycardia or bradycardia, which may affect maternal and fetal safety. Oxytocin can cause cardiovascular changes, including hypertension or arrhythmias, especially in clients with gestational hypertension. Continuous maternal cardiac assessment helps detect adverse effects early and adjust treatment accordingly.
Choice C rationale: Evaluating platelet count before induction is important in clients with gestational hypertension due to the risk of HELLP syndrome, which involves thrombocytopenia. Normal platelet levels range from 150,000 to 400,000/mm³; low levels increase bleeding risk during labor and delivery. Knowing platelet status guides safe management decisions, including anesthesia options and readiness for potential hemorrhagic complications.
Choice D rationale: Assessing for aspirin sensitivity is crucial because aspirin is often used in pregnancy for preeclampsia prevention. Aspirin hypersensitivity can lead to allergic reactions or exacerbation of asthma. Since the client has gestational hypertension, determining aspirin tolerance before administering medications is necessary to prevent adverse drug reactions and ensure safe pharmacologic management.
Choice E rationale: Reviewing the client’s history for heart disease documentation is vital as gestational hypertension increases cardiovascular risk. Preexisting heart conditions can complicate labor induction and oxytocin administration due to possible cardiac overload or arrhythmias. A comprehensive cardiac history ensures appropriate monitoring and interventions to prevent maternal and fetal complications during labor.
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