A nurse is caring for a client who is receiving epidural analgesia during labor. Which of the following findings is the nurse's first priority?

Temperature 38.2°C (100.8°F)

The client reports reduced sensation of the lower extremities.

The client reports generalized itching.

Blood pressure 80/52 mm Hg

Answer and Explanation

The Correct Answer is D

A: Elevated temperature during labor may be common and is not the nurse's first priority, especially when the client is receiving epidural analgesia, as it can be related to the stress of labor or other factors.
B: Reduced sensation of the lower extremities is an expected effect of epidural analgesia, and it is not the nurse's first priority unless it leads to complications such as motor weakness or respiratory distress.
C: Generalized itching is a common side effect of epidural analgesia due to opioids, and it can be managed with interventions such as antihistamines. However, it is not the nurse's first priority unless it is severe or accompanied by other concerning symptoms.
D: Epidural analgesia can cause vasodilation and decrease the client's blood pressure, which can lead to hypotension. Hypotension can be detrimental to both the mother and the baby and requires immediate attention to prevent complications. Therefore, the nurse's first priority is to address the low blood pressure.

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Correct Answer is C

Explanation

A. The client requires a rubella vaccination at this time. This is incorrect because rubella vaccination is contraindicated during pregnancy due to the risk of congenital rubella syndrome. Vaccination should be administered postpartum.

B. The client is not experiencing a rubella infection at this time. While this statement is true, it does not address the need for future immunization, which is the critical aspect of the interpretation.

C. The client requires a rubella immunization following delivery. This is correct because a negative rubella titer indicates that the client is not immune to rubella and should receive the vaccine postpartum to prevent future infection.

D. The client is immune to the rubella virus. This is incorrect because a negative rubella titer indicates a lack of immunity to rubella, meaning the client is susceptible to infection.

A. Administer a 500 mL bolus of 5% dextrose in water prior to the epidural administration. B. Inform the client that the anesthetic effect will last for approximately 6 hours. C. Obtain a 30 min electronic fetal monitoring (EFM) strip and prepare to give a bolus of Lactated Ringers solution prior to the epidural administration. D. Have the client stand very still at the bedside with her arms at her side.

Correct Answer is C

Explanation

A: Administering a 500 mL bolus of 5% dextrose in water is not necessary before the epidural administration, and it may not be recommended in active labor as it can increase the risk of fluid overload.

B: The duration of the anesthetic effect of the epidural can vary depending on the medication used, and it is not the nurse's priority during the preparation process.

C: Prior to administering epidural analgesia, the nurse should obtain a 30minute electronic fetal monitoring (EFM) strip to assess the fetal heart rate and monitor for any signs of fetal distress during the procedure.

D: Having the client stand very still with her arms at her side is not practical or necessary for epidural administration and could be uncomfortable for the client during labor.

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A nurse is caring for a client who is receiving epidural analgesia during labor. Which of the following findings is the nurse's first priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data?

Correct Answer is C

Explanation

A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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