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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Recording that the nurse was unable to take the patient’s temperature would not be the most appropriate action in this situation. The nurse can wait for a certain period of time and then take the patient’s temperature.
Choice B rationale
Continuing to take the oral temperature immediately after the patient has consumed ice chips could result in an inaccurately low temperature reading. The cold from the ice chips can temporarily lower the temperature in the mouth.
Choice C rationale
Waiting for 30 minutes and then returning to take the oral temperature is the most appropriate action. Consuming cold substances can lower the oral temperature temporarily, so it’s recommended to wait 15-30 minutes after the patient has consumed something cold before taking an oral temperature.
Choice D rationale
Giving the patient a sip of warm water, waiting for 5 minutes, and then taking the temperature is not the standard procedure. While it might help to normalize the temperature in the mouth more quickly, it’s generally recommended to wait at least 15-30 minutes after the patient has consumed something cold before taking an oral temperature.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Sensation of pressure is a common symptom of urinary retention due to prostatic hypertrophy.
Choice B rationale
Dysuria, or painful urination, can occur due to the enlarged prostate pressing against the urethra.
Choice C rationale
Bladder distension is a result of the bladder becoming overly full due to inability to fully empty the bladder.
Choice D rationale
Tenderness over the symphysis pubis can occur due to the bladder being overly full and distended.
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