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 B

Explanation

The correct answer is choice B. Apply ice to her perineal area.This is because ice can help reduce swelling and pain in the episiotomy wound, which is a cut made in the tissue between the vagina and anus during childbirth.Ice should be applied for the first 24 to 48 hours after delivery.

Choice A is wrong because Kegel exercises, which involve contracting and relaxing the pelvic floor muscles, are not recommended for the first 12 hours after an episiotomy.They can increase blood flow and inflammation in the area, and may interfere with healing.

Choice C is wrong because keeping her hips slightly elevated can cause pressure on the episiotomy wound and increase discomfort.It can also affect blood circulation and drainage in the area.

Choice D is wrong because observing her perineal area for signs of infection is not a nursing action that should be included in her plan of care for the first 12 hours.Infection is rare in episiotomy wounds, and signs of infection usually appear after 24 hours or later.However, the nurse should teach the patient how to keep the area clean and dry, and when to report any signs of infection, such as fever, pus, or foul-smelling discharge.

Normal ranges for episiotomy healing are:

• Stitches dissolve within 2 to 4 weeks

• Pain and swelling subside within a few days to a week

• Wound heals completely within 4 to 6 weeks

A. Hemorrhage. B. Urinary retention. C. Impending convulsion. D. Thrombophlebitis.

Correct Answer is C

Explanation

This is because pregnancy-induced hypertension (PIH) can cause eclampsia, a condition characterized by seizures and coma.Eclampsia can occur during pregnancy, labor, or postpartum.

A nurse should monitor the client for signs of increased blood pressure, headache, blurred vision, epigastric pain, and hyperreflexia, which may indicate an impending convulsion.

Choice A is wrong because hemorrhage is not a common complication of PIH.

Hemorrhage may occur due to other causes such as uterine atony, lacerations, or retained placenta.

Choice B is wrong because urinary retention is not a common complication of PIH.

Urinary retention may occur due to other causes such as anesthesia, trauma, or infection.

Choice D is wrong because thrombophlebitis is not a common complication of PIH.

Thrombophlebitis is a condition where a blood clot forms in a vein and causes inflammation.

It may occur due to other risk factors such as immobility, dehydration, or injury.

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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

A patient had an episiotomy during her delivery. Which nursing action should be included in her plan of care for the first 12 hours?

Correct Answer is B

Explanation

A client who had pregnancy-induced hypertension (PIH) is now postpartum. A nurse should closely monitor this client for which complication?

Correct Answer is C

Explanation

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When a pregnant patient has genital herpes, for which complication is the patient at higher risk than the general population?

A client is to receive ferrous sulfate tablets. Which drink item will enhance the absorption of the medication?

A patient who is 38 weeks pregnant and has tested positive for a chlamydial infection asks the nurse to discuss the baby's risk of becoming infected.Which information should the nurse include in discussion with the patient?

A client is at the antepartal clinic for a pregnancy test.Which finding, if present, would be considered a positive sign of pregnancy?

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?