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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Finasteride, a medication used to treat benign prostatic hypertrophy, can cause several side effects, including a decrease in libido or sexual desire.
Choice B rationale
There’s no specific interaction between finasteride and grapefruit juice. Therefore, patients don’t need to avoid grapefruit juice when taking this medication.
Choice C rationale
Finasteride can actually cause a decrease in PSA (prostate-specific antigen) levels. If a patient is having a PSA test, they should tell their doctor they are taking finasteride because it can affect the results.
Choice D rationale
It may take up to six months or more to see the full effects of finasteride. Therefore, patients should not expect to see a response within one week.
Correct Answer is D
Explanation
Choice A rationale
Lidocaine does not primarily serve to relieve pain when administered intravenously. It is primarily used as an antiarrhythmic agent.
Choice B rationale
Lidocaine does not slow intestinal motility. This is not one of its primary actions.
Choice C rationale
Lidocaine does not dissolve blood clots. It is not an anticoagulant.
Choice D rationale
Lidocaine prevents dysrhythmias. It is an antidysrhythmic medication that delays the conduction in the heart and reduces the automaticity of heart tissue.
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