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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Monitoring weight gain is correct because appropriate weight gain helps support fetal growth and reduces risks of complications such as gestational diabetes and preeclampsia.
Choice B reason:
Using nonprescription medications without provider approval is unsafe since many over-the-counter drugs (like NSAIDs or decongestants) can harm the fetus. This shows a need for further teaching.
Choice C reason:
Telling the provider before using home remedies is appropriate, as some herbs or supplements may be unsafe in pregnancy.
Choice D reason:
Reducing stress is correct because high maternal stress can negatively affect pregnancy outcomes and fetal development.
Correct Answer is B
Explanation
A. Incorrect. Weightbearing exercises should be avoided or limited during pregnancy, as they can increase the risk of injury, joint pain, and fatigue.
B. Correct. Moderate exercise can improve circulation, reduce swelling, and prevent varicose veins during pregnancy.
C. Incorrect. Resting for 30 minutes before each new exercise is not necessary and may reduce the benefits of physical activity.
D. Incorrect. Stretching exercises can help prevent muscle cramps, improve flexibility, and reduce back pain during pregnancy.
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