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 D
Explanation
The correct answer is: April 11, 2016
Choice A: April 27, 2016
Reason: Using Naegele’s Rule, the estimated date of delivery (EDD) is calculated by adding one year, subtracting three months, and adding seven days to the first day of the last menstrual period (LMP). For an LMP of May 4, 2015:
- Add one year: May 4, 2016
- Subtract three months: February 4, 2016
- Add seven days: February 11, 2016
April 27, 2016, is incorrect because it does not follow the correct calculation steps.
Choice B: April 11, 2016
Reason: Following Naegele’s Rule:
- Add one year: May 4, 2016
- Subtract three months: February 4, 2016
- Add seven days: February 11, 2016
April 11, 2016, is the correct EDD as it accurately follows the calculation steps.
Choice C: February 27, 2016
Reason: This date is incorrect because it does not follow the correct calculation steps of Naegele’s Rule. The correct EDD should be in April, not February.
Choice D: February 11, 2016
Reason: This date is also incorrect. While it follows the initial steps of Naegele’s Rule, it does not account for the full calculation, which should result in an April date, not February.
Correct Answer is D
Explanation
Choice A: "I should not drink alcoholic beverages during my pregnancy." Correct, as alcohol consumption during pregnancy can lead to fetal alcohol spectrum disorders and other adverse outcomes.
Choice B: "I should drink about 2 liters of fluid each day." Correct, as adequate hydration is essential during pregnancy.
Choice C: "I can have a moderate amount of caffeine daily." Correct, as moderate caffeine consumption is generally considered safe during pregnancy (around 200300 mg per day).
Choice D: During pregnancy, certain fish types can be high in mercury, which can be harmful to the developing fetus. Fish with high mercury levels should be limited or avoided during pregnancy.
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