Given the medical history and nurses’ notes of an infant diagnosed with Tetralogy of Fallot, which of the following actions should the nurse take?

Choice A rationale
Vomiting is not a common side effect of epidural anesthesia. Nausea can occur, but it is usually associated with the opioids used in the epidural, not the epidural itself.
Choice B rationale
Tachycardia, or a rapid heart rate, is not a typical side effect of epidural anesthesia. In fact, an epidural can sometimes cause a drop in heart rate, known as bradycardia.
Choice C rationale
Hypotension, or low blood pressure, is a common side effect of epidural anesthesia. The medication used in the epidural can cause blood vessels to relax, which can lower blood pressure.
Choice D rationale
Respiratory depression is not a common side effect of epidural anesthesia. The medication used in an epidural primarily affects the nerves in the lower body, so it does not typically impact breathing. Digoxin Digoxin Explore

Choice A rationale
The nurse should be concerned about a client with an 18kg (4 lb) weight gain in her first trimester. This is because the expected weight gain for a client in the first trimester is usually around 1.8 kg (4 lb)1. A weight gain of 18 kg in the first trimester significantly exceeds this expectation, which could indicate a potential health issue such as gestational diabetes or multiple pregnancies. It’s important for the nurse to report this finding to the healthcare provider for further evaluation and management.
Choice B rationale
A client with a 68 kg (15 lb) weight gain in her second trimester does not necessarily pose a concern. Weight gain during pregnancy varies among individuals and can be influenced by factors such as the mother’s body mass index (BMI) before pregnancy, the baby’s growth rate, and the mother’s diet and lifestyle. However, it’s always important to monitor weight gain throughout pregnancy to ensure it’s within a healthy range.
Choice C rationale
A client with a 13 kg (25 lb) weight gain in her third trimester does not necessarily pose a concern. Weight gain during the third trimester can be influenced by factors such as the baby’s growth rate, amniotic fluid volume, and the mother’s increased blood volume. However, it’s always important to monitor weight gain throughout pregnancy to ensure it’s within a healthy range.
Choice D rationale
A client with a 3.6 kg (8 lb) weight gain in her first trimester does not necessarily pose a concern. This is within the expected weight gain range for the first trimester. However, it’s always important to monitor weight gain throughout pregnancy to ensure it’s within a healthy range.