A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse's priority?
Blood pressure 80/56 mm Hg.
The client reports profuse itching.
The client reports weakness of the lower extremities.
Temperature 38.2°C (100.8 F).
The Correct Answer is A
Choice A reason:
The nurse's priority in this situation is the client's blood pressure of 80/56 mm Hg. Opioid epidural analgesia can cause a drop in blood pressure, known as hypotension. Hypotension can be a significant concern during labor, as it may reduce blood flow to the placenta and compromise the baby's well-being. Therefore, it is crucial for the nurse to address this finding promptly to prevent any adverse effects on both the mother and the baby. The nurse may need to administer intravenous fluids, adjust the dosage of the opioid medication, or take other appropriate actions to raise the blood pressure to a safer level.
Choice B reason:
While profuse itching (choice B) can be a common side effect of opioids, it is not the nurse's priority in this situation. Itching, also known as pruritus, can be managed with antihistamines or other supportive measures, but it is not an immediate threat to the client's well-being.
Choice C reason:
The client reporting weakness of the lower extremities (choice C) is an expected side effect of epidural analgesia. Epidurals can cause temporary paralysis or weakness in the lower body due to the local anesthetic's effects on the nerves. While it's essential to monitor and support the client during this time, it is not the priority over the potentially dangerous drop in blood pressure.
Choice D reason:
A temperature of 38.2°C (100.8 F) (choice D) may indicate a fever, but it is not the nurse's priority in this specific situation of opioid epidural analgesia during labor. Fever during labor could have various causes, and the nurse should investigate and manage it appropriately. However, addressing the client's blood pressure takes precedence, as hypotension can have immediate and significant consequences.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Changing the patient's gown may be necessary for comfort and hygiene, but it is not the priority after an amniotomy. The main concern is the well-being of the fetus and the mother.
Choice B reason:
Assessing the fetal heart rate is the priority after an amniotomy. This procedure involves rupturing the amniotic sac, which may lead to changes in the fetal environment. Monitoring the fetal heart rate helps determine if the baby is tolerating the procedure well and if there are any signs of distress.
Choice C reason:
Estimating the amount of amniotic fluid is essential during an amniotomy, but it is not the top priority. The focus should be on evaluating the fetal well-being first.
Choice D reason:
Assessing the color of the amniotic fluid is significant, but it is not the primary concern immediately after an amniotomy. While changes in fluid color may indicate certain conditions, the fetal heart rate assessment takes precedence in this situation.
Correct Answer is C
Explanation
Choice A reason:
Charting the normal axillary temperature is not the priority in this situation. The infant's temperature is subnormal, indicating hypothermia, which requires immediate intervention.
Choice B reason:
Rechecking the infant's temperature rectally may provide a more accurate reading, but it is not the priority action at this moment. The infant's low temperature indicates the need for immediate warming to prevent further complications.
Choice C reason:
Placing the infant in a radiant warmer is the priority nursing action. The axillary temperature of 35.9°C (96.6°F) is below the normal range for a newborn, which is around 36.5-37.5°C (97.7-99.5°F). Hypothermia in newborns can be dangerous and lead to respiratory distress, metabolic problems, and other complications. A radiant warmer provides a controlled heat source to warm the infant and stabilize their body temperature.
Choice D reason:
Having the mother breastfeed the infant may help provide warmth and comfort, but it is not the priority action. The immediate concern is to raise the infant's body temperature to a safe range using a radiant warmer.
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