A nurse is reinforcing teaching with a client who is in labor about why epidural anesthesia is not initiated until a good labor pattern has been established. Which of the following explanations should the nurse include?
"Given too soon, epidural anesthesia will delay rupture of fetal membranes.".
"Given too soon, epidural anesthesia can prolong labor.".
"Given too soon, epidural anesthesia can cause fetal depression.".
"Given too soon, epidural anesthesia can cause maternal hypertension.".
The Correct Answer is B
Choice A reason:
Initiating epidural anesthesia too soon may delay rupture of fetal membranes. This statement is not accurate. Epidural anesthesia itself does not have a direct impact on the rupture of fetal membranes. The timing of rupturing membranes is determined based on the progress of labor and other clinical indications. There is no causal relationship between epidural anesthesia and the timing of membrane rupture.
Choice B reason:
Initiating epidural anesthesia too soon can prolong labor. This statement is correct. Epidural anesthesia, while providing pain relief during labor, can also cause some degree of motor blockage and decrease the woman's ability to push effectively. This can potentially lead to a lengthening of the labor process. It is generally recommended to wait until a good labor pattern has been established to avoid unnecessary prolongation of labor.
Choice C reason:
Initiating epidural anesthesia too soon can cause fetal depression. This statement is not entirely accurate. Epidural anesthesia can cross the placenta and reach the fetus, but the effect on the baby is usually minimal. However, fetal monitoring is essential during labor to ensure the baby's well-being, regardless of whether epidural anesthesia is used or not.
Choice D reason:
Initiating epidural anesthesia too soon can cause maternal hypertension. This statement is not supported by evidence. Epidural anesthesia does not typically cause maternal hypertension. It can, however, lead to a decrease in blood pressure in some cases, which is why careful monitoring of maternal blood pressure is necessary during and after the administration of epidural anesthesia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale :
Hypercalcemia - The nurse does not need to monitor for hypercalcemia in this scenario. Hypercalcemia refers to high levels of calcium in the blood, and it is not directly related to the newborn's weight or the mother's diabetes mellitus.
Choice B rationale
Hypobilirubinemia - Hypobilirubinemia is low levels of bilirubin in the blood and is not a major concern for a newborn's weight or the mother's diabetes mellitus. Although jaundice (high bilirubin levels) can be a concern in newborns, it is not the focus in this case.
Choice C rationale
Hypoglycemia - This is the correct choice. Newborns of diabetic mothers are at risk of developing hypoglycemia, which is low blood sugar levels. The baby receives excess glucose from the mother during pregnancy, and after birth, insulin production may be higher than needed, leading to low blood sugar levels. Monitoring for hypoglycemia is crucial to prevent potential complications.
Choice D rationale
Decreased RBC - The nurse does not need to monitor for decreased red blood cells (RBC) specifically related to the newborn's weight or the mother's diabetes mellitus. Monitoring RBC levels is important for other conditions, but it is not the primary concern in this case.
Correct Answer is A
Explanation
Choice A rationale:
Visual disturbances should be reported to the provider because the client is experiencing headaches, blurred vision, and dizziness, which can be signs of preeclampsia. Preeclampsia is a serious condition that can develop during pregnancy and is characterized by high blood pressure and damage to organs like the liver and kidneys. Visual disturbances may indicate neurological involvement and can pose a risk to both the client and the fetus.
Choice B rationale:
Blood pressure should be reported to the provider due to the client's symptoms and medical history. The client's weight gain, swelling of feet and fingers, and 2+ pitting edema suggest fluid retention, which can be associated with preeclampsia. High blood pressure is a key diagnostic criterion for preeclampsia, and the nurse must monitor it closely to assess the severity of the condition and the potential risk to both the client and the fetus.
Choice C rationale:
Respirations do not appear to be a significant concern based on the information provided. While respiratory status is important to monitor during pregnancy, there are no indications in the scenario to suggest respiratory distress or abnormalities that require immediate reporting to the provider.
Choice D rationale:
Deep tendon reflexes are mentioned in the client's medical history but do not show any immediate signs of concern. Absent clonus and 3+ deep tendon reflexes are within the normal range and not typically alarming during pregnancy. However, the nurse should continue to monitor these reflexes during subsequent visits.
Choice E rationale:
Weight gain is mentioned in the medical history but is not currently a critical finding to report. A 6 lb weight gain over 2 weeks may be considered appropriate for a pregnant client at 32 weeks of gestation, but it should be assessed in conjunction with other symptoms for a comprehensive evaluation.
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