The nurse is monitoring a client in active labor who has an epidural in place. Which of the following findings should be reported to the anesthesiologist immediately? (Select All that Apply.)

Slurred speech

Respiratory depression

Decreased sensation in the lower extremities

Sustained fetal heart rate of 150 bpm

Blood pressure 108/62

Answer and Explanation

Correct Answer : A,B

A. Slurred speech – Slurred speech may indicate systemic absorption of the epidural medication, leading to toxicity or excessive central nervous system depression, which requires immediate intervention.

B. Respiratory depression – A serious complication of epidural anesthesia is respiratory depression, which may result from excessive medication spread, affecting respiratory function. Immediate intervention is required.

C. Decreased sensation in the lower extremities – This is an expected effect of an epidural and does not necessarily require immediate reporting unless it extends beyond expected levels.

D. Sustained fetal heart rate of 150 bpm – This fetal heart rate is within the normal range (110-160 bpm) and does not indicate distress.

E. Blood pressure 108/62 – While hypotension can be a side effect of epidural anesthesia, this blood pressure is within an acceptable range for many clients and does not require immediate intervention unless the client is symptomatic.

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Correct Answer is ["B","C","D"]

Explanation

A. Unexplained weight gain
This is incorrect because weight gain is not a characteristic symptom of endometriosis. Endometriosis primarily affects the reproductive organs and is associated with pain and infertility rather than metabolic or weight-related changes.

B. Pain during menstrual period
This is correct because dysmenorrhea (painful menstruation) is a hallmark symptom of endometriosis due to the presence of ectopic endometrial tissue responding to hormonal changes.

C. Pain during intercourse
This is correct because dyspareunia (pain during intercourse) is a common symptom of endometriosis due to the inflammatory and fibrotic changes caused by ectopic endometrial tissue.

D. Infertility
This is correct because endometriosis can lead to infertility due to scarring, adhesions, and inflammation affecting the fallopian tubes and ovaries. Many clients with endometriosis seek medical attention due to difficulty conceiving.

A. Liver function tests B. Blood pressure C. Heartburn D. Headache E. Gestational age F. Cardiac assessment

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}

Explanation

Priority concerns:

Liver function tests: The client has elevated ALT (75 U/L), AST (78 U/L), alkaline phosphatase (184 U/L), and LDH (250 U/L), which are consistent with liver involvement in preeclampsia with severe features. This suggests hepatic dysfunction and possible progression to HELLP syndrome.

Blood pressure: The client’s BP is 168/100 mmHg, which meets the criteria for severe preeclampsia (≥160/110 mmHg). Uncontrolled hypertension increases the risk of stroke, placental abruption, and progression to eclampsia.

Headache: The persistent headache could indicate severe preeclampsia with neurological involvement due to cerebral vasospasm and increased risk of stroke or seizure. A headache that does not resolve with usual measures is a warning sign, and magnesium sulfate should be considered for seizure prophylaxis.

Not a Priority Concern

Heartburn is a common symptom in pregnancy due to gastric reflux and increased progesterone levels, which relax the lower esophageal sphincter. While it can be uncomfortable, it is not immediately life-threatening.

Gestational age: The client is at 37 weeks’ gestation, which is considered early term but not preterm. While gestational age is important for delivery planning, it is not the most immediate concern compared to the client’s hypertensive crisis.

Cardiac assessment: The apical pulse is 77 bpm, regular, and lungs are clear, indicating that there is no immediate cardiac or respiratory compromise.

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The nurse is monitoring a client in active labor who has an epidural in place. Which of the following findings should be reported to the anesthesiologist immediately? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment findings might raise the nurse's suspicion of endometriosis in the client they are evaluating?

Correct Answer is ["B","C","D"]

Explanation

G1P1, 37 weeks' gestation patient with a scheduled nonstress test (NST) Identify which of the following findings is a priority concern or not for the patient.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}

Explanation

Based on the clients assessment on 2/11 at 1200, indicate if the client's condition is improving, worsening or not related based on the condition.

Which of the following gravid clients is most appropriate for a charge nurse to assign to a new nurse with no obstetric (OB) experience?

While caring for a client in labor, which assessment finding best indicates fetal well-being to the nurse?

G1P1, 37 weeks' gestation patient with a scheduled nonstress test (NST) Complete the following sentence using the drop-down options. The nurse's greatest concern is the client's risk of developing __i_____ and related to __ii____ and ___iii____.

A nurse is reviewing the differences between placenta previa and abruptio placentae with a group of nursing students. Which of the following statements accurately differentiates placenta previa from abruptio placentae?

A nurse is reviewing the different signs of pregnancy with a client who is in her first trimester. Which of the following symptoms should the nurse classify as a positive sign of pregnancy?

G1P1, 37 weeks' gestation patient with a scheduled nonstress test (NST) The nurse will implement the following interventions based on the fetal heart rate.(Select All that Apply.)