The nurse is caring for a client who is 40-weeks gestation in active labor and has received epidural anesthesia.
What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia?
Station of presenting part.
Maternal blood pressure.
Variability of fetal heart rate.
Level of pain sensation.
The Correct Answer is B
Choice A rationale
While assessing the station of the presenting part is important during labor, it is not the most crucial assessment following the administration of epidural anesthesia.
Choice B rationale
Monitoring maternal blood pressure is the most important assessment following the administration of epidural anesthesia. Epidural anesthesia can cause a drop in blood pressure, which can lead to complications for both the mother and the baby.
Choice C rationale
Although assessing the variability of the fetal heart rate is important during labor, it is not the most crucial assessment following the administration of epidural anesthesia.
Choice D rationale
While assessing the level of pain sensation is important to evaluate the effectiveness of the epidural anesthesia, it is not the most crucial assessment following its administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is **d. Monitor the infant for response to auditory stimuli**.
Choice A rationale:
Drawing an antibiotic trough level within 3 days is not a necessary action after a 14-day antibiotic treatment for bacterial meningitis in an infant. Trough levels are typically monitored during the course of treatment to ensure appropriate dosing, not after completion of therapy.
Choice B rationale:
Administering antipyretic medication continuously is not recommended after the completion of antibiotic treatment for bacterial meningitis. Fever is a common symptom during the acute phase of the illness, and the need for antipyretics should decrease as the infection is resolved.
Choice C rationale:
Continuing strict monitoring of daily wet diapers for 1 week is not a necessary action after the completion of antibiotic treatment for bacterial meningitis. Monitoring fluid intake and output is important during the acute phase of the illness, but not necessarily after the infant has completed the full course of antibiotics.
Choice D rationale:
Monitoring the infant for response to auditory stimuli is an important action to include when preparing the family for discharge after a 14-day antibiotic treatment for bacterial meningitis. Hearing loss is a potential complication of bacterial meningitis, and the infant should be evaluated for any hearing impairment before being discharged from the hospital.
Correct Answer is D
Explanation
Choice A rationale
While multiple gestation can cause an increase in maternal serum alpha-fetoprotein (MS-AFP) levels, it is not the most likely cause of an elevated MS-AFP level at 17 weeks.
Choice B rationale
Fetal hypoxia, or lack of oxygen to the fetus, is not typically associated with an increase in MSAFP levels.
Choice C rationale
Down syndrome is typically associated with lower, not higher, levels of MS-AFP891011.
Choice D rationale
An elevated level of MS-AFP at 17 weeks is most commonly associated with a neural tube defect. Neural tube defects are birth defects of the brain, spine, or spinal cord that occur during the first month of pregnancy.
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