A nurse is collecting data from a client who is receiving epidural anesthesia. Which of the following findings indicates an adverse effect of this method of pain management?

Tachycardia

Fever

Tachypnea

Hypertension

Answer and Explanation

The Correct Answer is C

A)   Incorrect- Tachycardia (elevated heart rate) can be a common physiological response to pain or other factors and is not necessarily indicative of an adverse effect of epidural anesthesia.
B)   Incorrect- Fever might be related to various factors, including infection, and is not directly indicative of an adverse effect of epidural anesthesia.
C)   Correct - Tachypnea (rapid breathing) can be an adverse effect of epidural anesthesia.

It can indicate that the anesthesia has spread too high in the spinal column, potentially affecting the respiratory muscles and causing respiratory distress.
D) Incorrect- Hypertension might be a side effect of epidural anesthesia, but tachypnea is a more specific indication of an adverse effect in this context.

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Correct Answer is C

Explanation

A) Incorrect- A reddened area on the calf might indicate a potential blood clot (deep vein thrombosis), which is important to assess but may not be the highest priority.
B) Incorrect- Painful uterine contractions during breastfeeding can be a normal response due to oxytocin release during breastfeeding and might not require immediate reporting.
C) Correct - A urinary output of 125 mL in 4 hours is significantly low and could indicate inadequate fluid intake, potential urinary retention, or other issues that need prompt attention. It is a sign of impaired renal function. This could indicate dehydration, blood loss, infection, or kidney injury. The nurse should assess the client's fluid intake and output, vital signs, urine specific gravity, and serum electrolyte levels. The nurse should also monitor the client for signs of hypovolemia, such as tachycardia, hypotension, and decreased skin turgor.
D) Incorrect- Changing a perineal pad every 2 hours is within the normal range for postpartum bleeding and might not require immediate reporting.

A. Set the temperature on the water heater to 48.8° C (120° F) B. Ensure the crib has soft bumper pads on the inside. C. Wash the newborn's face with a warm, soapy washcloth D. Place a small pillow under the newborn's head during naps

Correct Answer is C

Explanation

A) Incorrect- The water heater temperature should be set to 49.4°C (120°F) or below to prevent scalding. The given temperature is slightly too high.
B) Incorrect- Soft bumper pads in cribs can pose a suffocation risk and are not recommended.
C) Correct - Washing the newborn's face with a warm, soapy washcloth is a safe way to cleanse the baby's face. Harsh chemicals or strong soaps should be avoided.
D) Incorrect- Pillows should not be placed under a newborn's head during naps to reduce the risk of suffocation. The baby's sleep environment should be free of soft bedding.

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A nurse is collecting data from a client who is receiving epidural anesthesia. Which of the following findings indicates an adverse effect of this method of pain management?

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Naxlex Comprehensive Predictor Exams

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