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 C

Explanation

Choice A rationale

While asking the client's family to return may provide additional support, it is not a viable long-term solution as family members may have other responsibilities and commitments. It also places undue pressure on the family.

Choice B rationale

Hiring a private nurse could be a solution, but it may not be financially feasible for all clients. It also does not address the need for a comprehensive plan for both the client and her husband.

Choice C rationale

Social services can assist in arranging respite care for the client's husband, ensuring he receives the necessary care while the client recovers. Respite care is a practical solution for temporary relief for caregivers.

Choice D rationale

A case management evaluation can help assess the client's home environment and identify any potential needs or risks. However, it does not directly address the immediate concern of providing care for the husband.

Correct Answer is A

Explanation

Choice A rationale: Acute appendicitis is most likely based on the history of sudden onset of severe abdominal pain localized to the right lower quadrant, nausea, vomiting with green bile, and tenderness on physical examination. The ultrasound findings of right lower quadrant tenderness further support this diagnosis. The client's vital signs, including tachycardia and tachypnea, are consistent with the stress and pain caused by acute appendicitis.

Choice B rationale: Ectopic pregnancy is less likely as the client has a negative pregnancy test and reports regular menstrual cycles with her last period occurring one week ago. Additionally, her symptoms are more typical of appendicitis.

Choice C rationale: Ovarian cyst rupture would typically present with sudden onset of pelvic pain, often associated with menstrual irregularities or a history of ovarian cysts. However, the client's presentation and diagnostic results strongly point towards acute appendicitis.

Choice D rationale: Acute gastritis generally presents with epigastric pain, nausea, and vomiting. However, the localization of pain to the right lower quadrant and the ultrasound findings make appendicitis a more likely diagnosis in this case.

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