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 D
Explanation
The correct answer is: d. Move infant away from blowing fan.
Choice A: Dry the baby after a bath
Drying the baby after a bath is essential to prevent heat loss through evaporation. When a newborn is wet, the water on their skin can evaporate, taking heat away from their body. While this is an important step in maintaining the baby’s temperature, it does not specifically address heat loss through convection.
Choice B: Wrap the baby in warmed blankets
Wrapping the baby in warmed blankets helps prevent heat loss through conduction and radiation. Conduction occurs when the baby comes into contact with a cooler surface, and radiation occurs when the baby loses heat to the surrounding environment. Although this action is beneficial, it does not directly address heat loss through convection.
Choice C: Place the baby in a warmer
Placing the baby in a warmer is an effective way to maintain the baby’s overall body temperature by providing a controlled, warm environment. This action helps prevent heat loss through conduction, radiation, and evaporation. However, it is not the most direct method to prevent heat loss through convection.
Choice D: Move infant away from blowing fan
Moving the infant away from a blowing fan directly addresses and prevents heat loss due to air movement, which is a key factor in convection. Convection occurs when air currents carry heat away from the baby’s body. By moving the baby away from the fan, the nurse can effectively reduce heat loss through this mechanism.
Correct Answer is D
Explanation
A. Right occiput posterior position: This position refers to the baby's head being down but facing the mother's back, which can make labor more challenging but is not a contraindication for amniotomy.
B. -2 station: This indicates that the baby's head is not yet engaged in the pelvis. While it can complicate labor, it is not an absolute contraindication for amniotomy, though caution is advised.
C. Cephalic presentation: This is the most common and favorable position for delivery, where the baby's head is down and ready for birth. It is not a contraindication for amniotomy.
D. Dilation less than 3 cm: This is a contraindication for amniotomy because the cervix is not sufficiently dilated, which can increase the risk of complications such as infection or prolonged labor.
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