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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

Keeping plastic bags of ice in the freezer is not specifically indicative of successful management of hemophilia. While ice can be used to manage acute joint bleeds, it does not reflect the overall management of the condition.

Choice B rationale

Wearing extra pads when playing football could indicate an awareness of the risk of injury, but it does not necessarily reflect successful management of hemophilia. In fact, contact sports like football are generally not recommended for individuals with hemophilia due to the risk of bleeding.

Choice C rationale

Serving as a counselor at a camp for hemophiliacs could indicate successful management of hemophilia. It suggests that the individual has not only learned to manage their own condition, but is also able to provide guidance and support to others with the same condition.

Choice D rationale

Chewing food slowly to prevent injury to the gums is a precautionary measure, but it does not necessarily indicate successful management of hemophilia.

A. Report heart rate to healthcare provider. B. Assess perineum for excessive lochia. C. Document the vital signs in the record. D. Administer a PRN dose of acetaminophen.

Correct Answer is C

Explanation

Choice A rationale
A heart rate of 58 beats/minute is within the normal range for adults, including those who have recently given birth. Therefore, there is no need to report this to the healthcare provider.
Choice B rationale
While assessing for excessive lochia is important in postpartum care, there is no indication from the given vital signs that this is necessary.
Choice C rationale
The vital signs provided are all within normal ranges for a postpartum patient. Therefore, the appropriate action would be to document these findings in the patient’s record.
Choice D rationale
There is no indication from the given vital signs that the patient has a fever or pain, so administering a PRN dose of acetaminophen is not necessary.

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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?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adolescent client who has successfully managed hemophilia for the past 10 years is evaluated by the nurse. Which behavior best evidences the client’s adjustment to the disorder as an adolescent?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4° F (38° C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?

Correct Answer is C

Explanation

A client who experienced a severe postpartum hemorrhage following the vaginal birth of twins is transferred to the postpartum unit. The nurse knows that assessment for which complication is the highest priority for this client?

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The nurse is caring for a toddler with a large, unrepaired ventricular septal defect and heart failure. What assessment finding should the nurse anticipate?

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?