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
The correct answer is: a. Hyperbilirubinemia.
Choice A: Hyperbilirubinemia
Reason: Hyperbilirubinemia in newborns is often caused by the increased breakdown of red blood cells, which have a shorter lifespan in neonates. This breakdown produces bilirubin, a yellow pigment that can accumulate in the blood, leading to jaundice. The liver of a newborn is not fully mature and may not be able to process and excrete bilirubin efficiently, resulting in hyperbilirubinemia.
Choice B: Respiratory Distress Syndrome
Reason: Respiratory Distress Syndrome (RDS) is primarily caused by a deficiency of surfactant in the lungs, which is more common in premature infants. It is not directly related to the lifespan of red blood cells. Symptoms include rapid, shallow breathing and a bluish color due to lack of oxygen.
Choice C: Polycythemia
Reason: Polycythemia is characterized by an abnormally high concentration of red blood cells. It is often due to factors like delayed cord clamping or maternal diabetes, rather than the decreased lifespan of red blood cells. Polycythemia can lead to increased blood viscosity and complications such as sluggish blood flow.
Choice D: Transient Tachypnea
Reason: Transient Tachypnea of the Newborn (TTN) is a respiratory condition caused by delayed clearance of fetal lung fluid. It typically resolves within a few days and is not related to the lifespan of red blood cells. Symptoms include rapid breathing and grunting.
Correct Answer is D
Explanation
Choice A reason:
The woman in early labor with contractions every 5 minutes lasting 40 seconds each does not require the immediate discontinuation of the oxytocin (Pitocin) infusion. Early labor is characterized by mild and infrequent contractions as the cervix begins to dilate and efface. Choice B reason:
The woman in active labor with contractions every 30 minutes lasting 60 seconds each also does not warrant immediate discontinuation of the oxytocin (Pitocin) infusion. Active labor typically involves regular and stronger contractions as the cervix continues to dilate and the baby progresses downward.
Choice C reason:
The woman in active labor with contractions every 2 to 3 minutes lasting 70 to 80 seconds each does not require immediate cessation of the oxytocin (Pitocin) infusion. These contractions are within the expected range for active labor and may be considered normal.
Choice D reason:
The woman in transition with contractions every 1.5 minutes lasting 95 seconds each should have the oxytocin (Pitocin) infusion discontinued immediately. Transition is the most intense phase of labor, characterized by rapid and strong contractions as the cervix completes dilation. Prolonged and frequent contractions during this phase can lead to uterine hyperstimulation, which can compromise fetal oxygenation and result in fetal distress. Discontinuing the oxytocin infusion is necessary to reduce the intensity and frequency of contractions, ensuring better fetal well-being during this critical phase of labor.
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