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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Related Questions
Correct Answer is B
Explanation
Choice A: Elevating the client's legs is a measure to increase blood flow to the brain in cases of orthostatic hypotension but may not be sufficient to improve fetal oxygenation in this situation. The lateral position is preferred as it improves uterine perfusion.
Choice B: The client's blood pressure of 80/40 mm Hg indicates hypotension, which can be a common side effect of epidural anesthesia. The priority nursing action is to place the client in a lateral (sidelying) position to improve blood flow to vital organs, including the uterus and placenta, and prevent further compromise of fetal oxygenation.
Choice C: Monitoring vital signs every 5 minutes is an important nursing action, but the priority in this situation is to address the hypotension and improve maternal and fetal wellbeing first.
Choice D: Notifying the provider is an important step, but it should not be the first action. Immediate intervention to address the hypotension is required to improve fetal oxygenation.
Correct Answer is C
Explanation
Choice A: Fetal movements, also known as quickening, are usually felt by the mother between weeks 18 and 25 of pregnancy, not specifically at week 24.
Choice B: While the sex of the baby is determined at conception, it is not visually identifiable on ultrasound until around week 16 to 20, depending on the fetus's position and the quality of the ultrasound images.
Choice C: The baby's heartbeat can be visualized on ultrasound as early as 6 weeks of pregnancy. It becomes audible using a Doppler stethoscope around 8 to 9 weeks of pregnancy.
Choice D: Lanugo, the fine hair covering the baby's body, usually appears around weeks 20 to 24 of pregnancy and begins to diminish later in pregnancy, not specifically at week 36.
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