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 A
Explanation
Choice A reason:
Maternal exhaustion is a maternal indication for the use of vacuum extraction. Vacuum extraction is a technique that can assist the mother in delivering the baby when she is unable to push effectively or when pushing poses a risk to her health. Vacuum extraction can shorten the second stage of labor and reduce maternal fatigue and distress. According to the Cleveland Clinic, vacuum extraction might be indicated if "the mother can't push anymore, either due to exhaustion or a health condition.".
Choice B reason:
Failure to progress past 0 station is not a maternal indication for the use of vacuum extraction. The station refers to the position of the baby's head in relation to the mother's pelvis. 0 station means that the baby's head is at the level of the pelvic inlet, or the narrowest part of the pelvis. Vacuum extraction is usually not performed before the baby reaches +2 station, which means that the head is 2 cm below the pelvic inlet and visible at the vaginal opening. According to the American Academy of Family Physicians, vacuum extraction should not be attempted if "the fetal head is not engaged (above 0 station).".
Choice C reason:
A wide pelvic outlet is not a maternal indication for the use of vacuum extraction. The pelvic outlet is the lower part of the pelvis that forms the exit for the baby during delivery. A wide pelvic outlet means that there is more space for the baby to pass through, which can facilitate vaginal delivery and reduce the need for instrumental assistance. Vacuum extraction is more likely to be indicated when there is a narrow pelvic outlet, which can obstruct labor and cause fetal distress.
Choice D reason:
A history of rapid deliveries is not a maternal indication for the use of vacuum extraction. Rapid deliveries, also known as precipitous deliveries, are those that occur within 3 hours of the onset of labor. Rapid deliveries can pose risks to both the mother and the baby, such as excessive bleeding, umbilical cord prolapse, or birth trauma. However, vacuum extraction is not usually indicated in these cases, as it requires time and preparation to apply the device and monitor its effects. Vacuum extraction is more likely to be indicated when labor is prolonged or stalled in the second stage, and when there is a nonreassuring fetal heart rate.
Correct Answer is C
Explanation
Choice A reason:
While hypoglycemia (glucose <45 mg/dL) is concerning,58 mg/dLis within acceptable ranges for many institutions, especially in asymptomatic newborns. Monitoring is required, but it is less urgent than respiratory distress.
Choice B reason:
Respiratory rate of 78 breaths per minute is also within the normal range for a newborn, which typically ranges from 30 to 60 breaths per minute. Though respiratory rate is essential to assess, it does not take priority over other critical issues.
Choice C reason:
Newborns typically have a normal respiratory rate of30-60 breaths/minute. A rate of78indicatessignificant tachypnea, which could signal respiratory distress (e.g., transient tachypnea of the newborn, infection, or respiratory distress syndrome). Rapid breathing can lead to fatigue, hypoxia, or respiratory failure if not promptly addressed.
Choice D reason:
A glucose reading of 58 mg/dL is concerning in a newborn. Hypoglycemia (low blood glucose) can lead to serious complications if not promptly addressed. Newborns are particularly susceptible to hypoglycemia, and it requires immediate assessment and intervention.
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