How it Works
Try Naxlex NCLEX-RN (Free-Trial)

Scenario:
A nurse is caring for a 26-year-old gravida 2 para 1 female client in the labor and delivery unit.

Exhibits
The client receiving epidural anesthesia would be at risk for developing due to .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E"}

Epidural anesthesia can cause vasodilation and a resultant drop in blood pressure, hence the importance of close monitoring and IV fluid administration to maintain blood pressure levels.

Risk Factors:

  1. Peripheral vasodilation: This is related to the relaxation of blood vessels, which can lead to a drop in blood pressure (hypotension). It is not a direct risk on its own but a cause of hypotension.
  2. Hypotension: This is the correct answer. Epidural anesthesia can cause a significant drop in blood pressure due to vasodilation.
  3. Urinary retention: This can occur with epidural anesthesia as the sensation to urinate may be diminished, causing the bladder to fill and potentially lead to bladder distention and discomfort.
  4. Fluid overload: This is less commonly associated with epidural anesthesia. It is typically related to excessive intravenous fluid administration.

Causes:

  1. Inadequate pain relief: This would not directly cause the issues mentioned above but would indicate that the epidural is not effectively managing the client's pain.
  2. Decreased fetal heart rate: This can be a consequence of maternal hypotension, which reduces blood flow to the placenta.
  3. Full urinary bladder: This can be a result of urinary retention due to the effects of the epidural, but it is not a direct cause of hypotension.
  4. Inability to push: This can occur with epidural anesthesia as it may decrease the ability to feel contractions and effectively push during delivery, but it is not related to hypotension.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is A

Explanation

Choice A rationale

The scenario indicates that the client's contractions are increasing in frequency and intensity, and she reports significant pain, prompting a request for an epidural. The cervical exam shows she is 5 cm dilated and 90% effaced, with the baby at 0 station, which is typical for the active phase of labor. This is the appropriate time for an epidural, as pain management is often needed when contractions become more intense and dilation progresses. Clear amniotic fluid after artificial rupture of membranes also suggests no immediate complications.

Choice B rationale

Immediate cesarean section is generally reserved for situations of fetal distress or other obstetric emergencies. There is no mention of fetal heart rate abnormalities or other signs of distress in the scenario. While MS can complicate pregnancy, it does not automatically necessitate a cesarean section without specific indications. The decision for cesarean should be based on maternal or fetal indications not present in this case.

Choice C rationale

The instruction to start pushing is only appropriate during the second stage of labor when the cervix is fully dilated (10 cm). The client is 5 cm dilated, indicating she is still in the active phase of the first stage of labor. Encouraging pushing at this stage would be premature and could cause unnecessary exhaustion and potential harm to the cervix and fetus. Pushing is typically reserved for the final stage when the baby's head is crowning.

Choice D rationale

Administering an epidural and experiencing immediate pain relief aligns with the standard protocol for labor analgesia when requested by the client. Epidural anesthesia is a common and effective method for pain management during labor. This option respects the client's expressed need for pain relief and involves the healthcare provider in safely administering the epidural. Immediate relief from pain can help the client focus on labor progression and reduce stress.

Correct Answer is ["1000"]

Explanation

Step 1 is 500 mL ÷ 30 min.

Step 2 is 16.67 mL/min × 60 min/hour. Answer: 1000 mL/hour.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register