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
A. Maintain the client in the lithotomy position: The lithotomy position is not typically
maintained during the active phase of labor. It is used during the pushing stage (second stage) of labor.
B. Encourage the client to empty her bladder every 2 hr: A full bladder can impede fetal descent and progress during labor, so encouraging the client to empty her bladder regularly is essential.
C. Remind the client to bear down with each contraction: Bearing down during the active phase of labor is not appropriate, as it may lead to premature pushing and cervical swelling.
D. Perform vaginal examinations frequently: Frequent vaginal examinations can increase the risk of infection and should be minimized during labor.
Correct Answer is A
Explanation
Choice A: Urinary frequency is a common symptom during pregnancy, especially in the first trimester and near the end of the pregnancy. During the first trimester, it is mainly due to
hormonal changes and increased blood flow to the pelvic area. In the later stages, it is caused by the growing uterus putting pressure on the bladder.
Choice B: Dismissing the client's concern as a minor inconvenience is not appropriate and may disregard the client's experience.
Choice C: While it is true that each individual client's experience may vary, it is important to provide the client with information regarding common patterns.
Choice D: Providing accurate information about the duration of urinary frequency is important. While it may last until the 12th week for many women, it does not continue throughout the entire pregnancy for most individuals, regardless of bladder tone.
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