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 D

Explanation

Choice A: Smoking is not directly associated with the development of type 1 diabetes mellitus in the baby.

Choice B: While smoking during pregnancy can have various effects on the baby's health, hearing loss is not one of the common complications.

Choice C: Although smoking during pregnancy is associated with an increased risk of congenital heart defects, intrauterine growth restriction is a more likely complication based on the client's smoking history.

Choice D: Smoking during pregnancy is associated with various adverse outcomes for both the mother and the baby. It can cause intrauterine growth restriction (IUGR), where the baby does not grow at the expected rate and has a lower birth weight. Smoking reduces blood flow to the placenta, which can affect the baby's growth and development.

A. "You should take a deep, cleansing breath and breathe naturally." B. "You should go ahead and push as hard as you can to assist the delivery." C. "You should try to blow or pant as the baby is being born to help avoid a toorapid birth." D. "You should try to perform slowpaced breathing patterns."

Correct Answer is C

Explanation

A: Taking deep, cleansing breaths and breathing naturally is not the appropriate technique during the crowning phase of labor, as it can increase the risk of rapid birth and potential perineal trauma.

C: During a precipitous labor with the baby's head crowning, the nurse should encourage the mother to perform blowing or panting breaths during contractions. This technique helps to slow down the delivery process and allows the perineum to stretch gradually, reducing the risk of tearing or other trauma.

B: In the case of precipitous labor, actively pushing as hard as possible can increase the risk of rapid birth and potential complications for both the mother and the baby.

D: Slowpaced breathing patterns are not recommended during the crowning phase of labor, as they may not effectively control the birth process.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Correct Answer is C

Explanation

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