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 ["A","B","C","D","E","F","G","H"]
Explanation
Step 1: The patient’s vital signs are as follows: Temperature 100.4° F (38° C) orally, Heart rate 86 beats/minute, Respiratory rate 16 breaths/minute, Blood pressure 102/12 mm Hg, Pain 4 on a 0 to 10 pain scale.
Step 2: She was assisted to the bathroom where she voided 150 mL of clear yellow urine. Lochia rubra is moderate with small clots, no foul odor noted. The fundus is firm at the umbilicus. The episiotomy edges are well approximated, with no redness, edema, drainage, or ecchymosis. There is no pain, redness, or swelling in the calves.
Step 3: A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing via an 18-gauge peripheral IV in the left forearm at 125 mL per hour, with 500 mL remaining in the bag. The IV is patent, without redness or swelling, and can be discontinued when this bag’s infusion is complete.
Correct Answer is C
Explanation
Choice A rationale
Variance in blood pressure across extremities is not typically associated with ventricular septal defects (VSDs). VSDs are characterized by a hole in the heart that allows oxygen-rich blood to move back into the lungs instead of being pumped to the rest of the body.
Choice B rationale
Hypotension is not a common symptom of VSDs. Instead, these defects can cause increased blood pressure in the lungs due to the abnormal flow of blood.
Choice C rationale
Tachycardia, or a rapid heart rate, is a common symptom of VSDs, especially in cases where the defect is medium or large. This is because the heart needs to work harder to pump blood, leading to an increased heart rate.
Choice D rationale
While pulse oximetry readings within defined limits could be seen in small VSDs, in larger defects or those causing heart failure, oxygen saturation levels might be lower due to the abnormal circulation of blood.
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