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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.


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Related Questions

Correct Answer is B

Explanation

Choice A rationale

Starting with the most difficult tasks can be overwhelming for the client and may increase anxiety. When interviewing a client suspected of domestic violence, it is important to build rapport and trust first by starting with less sensitive topics. This approach allows the client to feel more comfortable and secure before discussing more difficult issues.

Choice B rationale

Beginning with tasks that are less sensitive in nature helps to build rapport and trust with the client. This approach allows the nurse to establish a safe and supportive environment, making the client more likely to open up about sensitive issues such as domestic violence. Establishing a connection with the client is crucial for effective communication and assessment.

Choice C rationale

Asking vague, non-specific questions can lead to unclear and incomplete information. It is important to ask clear, specific questions to gather accurate information about the client's situation. This approach helps to ensure that the nurse obtains a comprehensive understanding of the client's needs and concerns.

Choice D rationale

Sharing personal values to put the client at ease is not appropriate in a professional setting. The nurse's role is to provide unbiased and non-judgmental care. Sharing personal values can create a sense of discomfort or pressure for the client, hindering effective communication and trust-building.

Correct Answer is ["A","D"]

Explanation

Choice A rationale: Oxygen saturation of 56% is critically low and indicates severe hypoxemia, which requires immediate intervention to improve oxygenation and prevent life-threatening complications.

Choice D rationale: Tracheal deviation to the right suggests a possible tension pneumothorax, which is a medical emergency. It requires immediate attention to relieve the pressure on the affected lung and restore normal breathing.

Choice B rationale: Crackles heard in the right lung indicate fluid or atelectasis but are not immediately life-threatening compared to the other findings.

Choice C rationale: A pH of 7.21 indicates acidemia and respiratory acidosis but is a secondary concern compared to the immediate need to address the client's hypoxemia and potential tension pneumothorax.

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