A nurse is caring for a client who is receiving epidural analgesia during labor.Which of the following symptoms should the nurse report to the physician?
Temperature 37.8°C (100.3°F).
Generalized itching.
The client reports weakness of the lower extremities.
Fetal bradycardia.
The Correct Answer is D
Choice A rationale
A temperature of 37.8°C (100.3°F) is a low-grade fever that does not typically indicate a serious issue in the context of epidural analgesia during labor. It should be monitored, but it's not immediately concerning.
Choice B rationale
Generalized itching can be a common side effect of epidural analgesia due to the opioids used. It should be monitored and managed, but it does not typically require immediate physician notification.
Choice C rationale
Weakness of the lower extremities can be expected with epidural analgesia as it causes a loss of sensation and muscle control. This should be monitored, but it is not typically an emergency.
Choice D rationale
Fetal bradycardia is a serious concern that must be reported to the physician immediately. It can indicate fetal distress and requires urgent evaluation and intervention to ensure the well-being of the baby. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Premature rupture of the membranes refers to the breaking of the amniotic sac before labor starts. It is not a definitive indicator of true labor, as contractions and cervical changes need to accompany it to confirm labor onset.
Choice B rationale
Light irregular pattern of contractions is often associated with false labor or Braxton Hicks contractions. True labor contractions are typically regular, progressively stronger, and closer together.
Choice C rationale
3 station of the presenting part refers to the baby's descent into the pelvis. While it indicates labor progression, it is not the most definitive sign of true labor compared to cervical changes.
Choice D rationale
Progressive cervical dilation is the most reliable indicator of true labor. It signifies that the cervix is opening up in response to regular and effective contractions, indicating the body is preparing for childbirth.
Correct Answer is B
Explanation
Choice A rationale
2 cm dilated, 60% effaced, 2 cm below the ischial spines is incorrect because the -2 station means the presenting part is above the ischial spines, not below.
Choice B rationale
2 cm dilated, 60% effaced, 2 cm above the ischial spines correctly interprets the given data: cervical dilation, effacement, and station relative to the ischial spines.
Choice C rationale
2 cm effaced, 60% dilated, 2 cm below the ischial spines is incorrect because it reverses effacement and dilation figures and incorrectly places the station.
Choice D rationale
2 cm effaced, 60% dilated, 2 cm above the ischial spines is incorrect due to reversed effacement and dilation figures, though the station is correctly above the ischial spines.
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