A nurse is caring for a patient receiving epidural analgesia for pain during labor. Which of the following observations should be the nurse’s priority?

The patient’s blood pressure is 80/56 mm Hg.

The patient reports lower extremity weakness.

The patient’s temperature is 38.2°C (100.8 F).

The patient reports severe itching.

Answer and Explanation

The Correct Answer is A

Choice A rationale

The patient’s blood pressure is significantly low, which could indicate hypotension, a serious side effect of epidural analgesia. This should be the nurse’s priority as it can lead to complications such as decreased perfusion to vital organs.

Choice B rationale

Lower extremity weakness can be a side effect of epidural analgesia, but it is not as immediately life-threatening as hypotension.

Choice C rationale

A slight increase in temperature may not be an immediate concern unless it continues to rise or is accompanied by other signs of infection.

Choice D rationale

Severe itching can be a side effect of epidural analgesia, but it is not as immediately life- threatening as hypotension.

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Correct Answer is ["A","D"]

Explanation

Choice A rationale

Metoclopramide is a medication used for stomach and esophageal problems. It is commonly used to treat and prevent nausea and vomiting, to help with emptying of the stomach in people

with delayed stomach emptying, and to help with gastroesophageal reflux disease. The antiemetic action of metoclopramide is due to its antagonist activity at D2 receptors in the chemoreceptor trigger zone in the central nervous system — this action prevents nausea and vomiting triggered by most stimuli.

Choice B rationale

While metoclopramide does have an effect on the muscles of the gastrointestinal tract, it does not work by relaxing them. Instead, it works by blocking dopamine receptors, which in turn stimulates motility in the upper gastrointestinal tract without stimulating gastric, biliary, or pancreatic secretions. This increased motility helps to speed up the rate at which the stomach empties into the intestines.

Choice C rationale

Metoclopramide does not work by decreasing gastric acid secretions. In fact, one unique property of this drug is that it does not increase gastric acid secretion. Its primary mechanism of action is to block dopamine receptors, thereby increasing muscle contractions in the upper digestive tract.

Choice D rationale

This is correct. Metoclopramide enhances gastric emptying. It is used to treat conditions like gastroesophageal reflux disease and diabetic gastroparesis, where delayed gastric emptying is a problem. By blocking dopamine receptors, metoclopramide increases muscle contractions in the upper digestive tract, speeding up the rate at which the stomach empties into the intestines.

A. Lower quadrant pain B. Cullen’s sign C. Goodell’s sign D. Chadwick’s sign

Correct Answer is B

Explanation

Choice A rationale

Lower quadrant pain is a common symptom of many conditions, including ectopic pregnancy. However, it does not specifically indicate the presence of blood in the peritoneum.

Choice B rationale

Cullen’s sign, which is the appearance of bruising in the skin around the umbilicus, is a sign of blood in the peritoneum. It can occur in conditions such as a ruptured ectopic pregnancy.

Choice C rationale

Goodell’s sign is a softening of the cervix that typically occurs early in pregnancy. It does not indicate the presence of blood in the peritoneum.

Choice D rationale

Chadwick’s sign is a bluish discoloration of the cervix, vagina, and labia that occurs in early pregnancy. It does not indicate the presence of blood in the peritoneum.

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A nurse is caring for a patient receiving epidural analgesia for pain during labor. Which of the following observations should be the nurse’s priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has nausea and a prescription for metoclopramide intravenously every 8 hours as needed. The client asks the nurse how metoclopramide will relieve her nausea. Which explanation should the nurse provide?

Correct Answer is ["A","D"]

Explanation

A nurse in the emergency department is caring for a patient who reports severe abdominal pain in the left quadrant. The healthcare provider suspects a ruptured ectopic pregnancy.What sign should the nurse look for that indicates the patient has blood in the peritoneum?

Correct Answer is B

Explanation

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