A patient who is 37 weeks pregnant and has gestational diabetes is admitted to the labor and delivery unit for induction.
The patient is placed on an external fetal monitor and receives an epidural anesthesia.Which action should the nurse take to identify a potential side effect of the epidural?

Assess the patient’s urine for acetone.

Monitor the patient’s deep tendon reflexes.

Assess the patient’s pupillary accommodation.

Monitor the patient’s blood pressure.

Answer and Explanation

The Correct Answer is D

This is because epidural anesthesia can cause hypotension (low blood pressure) which can affect the placental blood flow and fetal oxygenation.

The nurse should monitor the patient’s blood pressure frequently and intervene if it drops below the baseline.

Choice A is wrong because assessing the patient’s urine for acetone is not relevant to the side effects of epidural anesthesia. Acetone in urine can indicate diabetic ketoacidosis, a complication of diabetes that occurs when the body breaks down fat for energy due to lack of insulin.

However, this is not related to epidural anesthesia.

Choice B is wrong because monitoring the patient’s deep tendon reflexes is not relevant to the side effects of epidural anesthesia. Deep tendon reflexes can be affected by magnesium sulfate, a medication used to prevent seizures in patients with preeclampsia (a condition characterized by high blood pressure and proteinuria in pregnancy).

However, this is not related to epidural anesthesia.

Choice C is wrong because assessing the patient’s pupillary accommodation is not relevant to the side effects of epidural anesthesia.

Pupillary accommodation is the ability of the eye to adjust its focus from distant to near objects. It can be impaired by drugs that affect the nervous system, such as opioids or anticholinergics.

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Correct Answer is C

Explanation

This is because urine toxicology studies can detect the presence of cocaine and other drugs in the body of the pregnant woman and her unborn baby.Cocaine use during pregnancy can have serious consequences for both the mother and the baby, such as high blood pressure, premature labor, low birth weight, and developmental problems.

Choice A is wrong because urine estriol levels are used to measure the activity of the placenta and the fetal adrenal glands.They are not related to cocaine use.

Choice B is wrong because serum bilirubin levels are used to assess the liver function and the risk of jaundice in newborns.They are not related to cocaine use.

Choice D is wrong because lecithin-sphingomyelin ratio is used to evaluate the fetal lung maturity and the risk of respiratory distress syndrome.It is not related to cocaine use.

A. Manually express colostrum as necessary. B. Apply hot compresses to the breasts. C. Massage the breast tissue surrounding the areola. D. Wear a supportive bra.

Correct Answer is D

Explanation

The correct answer is choice D. Wear a supportive bra.This will help suppress lactation and reduce the discomfort of engorgement.

The other choices are wrong because:

• Choice A. Manually express colostrum as necessary.This will stimulate milk production and prolong engorgement.

• Choice B. Apply hot compresses to the breasts.This will increase blood flow and swelling in the breasts and worsen engorgement.

• Choice C. Massage the breast tissue surrounding the areola.This will also stimulate milk production and prolong engorgement.

Normal ranges for breast engorgement are not applicable as it is a subjective experience that varies among women.However, some signs of engorgement include firm, tender, swollen breasts, flat or inverted nipples, and low-grade fever.Engorgement usually resolves within 24 to 36 hours after it begins.

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A patient who is 37 weeks pregnant and has gestational diabetes is admitted to the labor and delivery unit for induction. The patient is placed on an external fetal monitor and receives an epidural anesthesia.Which action should the nurse take to identify a potential side effect of the epidural?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When a client reports using cocaine during her current pregnancy, which laboratory study should a nurse anticipate?

Correct Answer is C

Explanation

A patient has decided to bottle-feed her twins.The nurse should give this patient which instruction to help alleviate breast engorgement?

Correct Answer is D

Explanation

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A patient who is 37 weeks pregnant and has gestational diabetes is admitted to the labor and delivery unit for induction.
The patient is placed on an external fetal monitor and receives an epidural anesthesia.Which action should the nurse take to identify a potential side effect of the epidural?