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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
The correct answer is B, C, and D.
Choice A: Increase the oxytocin infusion to 13 mu/min
Increasing the oxytocin infusion is not indicated in this scenario. Oxytocin is used to induce or augment labor, but if the fetal heart rate tracing is abnormal (Category 3), increasing oxytocin could exacerbate fetal distress. The priority is to stabilize the fetal condition before considering increasing oxytocin.
Choice B: Initiate a bolus of primary IV fluids
Initiating a bolus of primary IV fluids is appropriate. This action helps improve placental perfusion and maternal hydration, which can be beneficial in response to abnormal fetal heart rate tracings. Adequate hydration can enhance uteroplacental blood flow and improve fetal oxygenation.
Choice C: Place the client in a sidelying position
Placing the client in a sidelying position is recommended. This position can improve uteroplacental perfusion and fetal oxygenation, especially if there are signs of fetal distress. It helps to alleviate pressure on the inferior vena cava, enhancing blood flow to the placenta.
Choice D: Apply oxygen at 10 L/min via a venturi mask
While oxygen may be indicated for fetal distress, the correct method is usually a non-rebreather mask at 10 L/min, not a venturi mask. A venturi mask delivers more precise oxygen concentrations but not high-flow oxygen, which is needed in this scenario.
Choice E: Perform a sterile vaginal examination (SVE)
A vaginal exam assesses labor progression, cervical dilation, station, and fetal position. This is important for determining whether labor is progressing appropriately or whether further interventions are needed.
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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