What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?
Level of pain sensation.
Variability of fetal heart rate
Maternal blood pressure
Station of presenting part
The Correct Answer is C
Level of pain sensation:
This is important for assessing the effectiveness of the epidural anesthesia, but it's not the most critical assessment immediately after administration.
Variability of fetal heart rate:
Monitoring fetal heart rate is always important, but immediately following epidural administration, the maternal blood pressure is a more immediate concern.
Maternal blood pressure:
This is the most critical assessment after epidural administration. Epidurals can cause a sudden drop in blood pressure, which may affect blood flow to the baby.
Station of presenting part:
The station of the presenting part (the position of the baby's head in relation to the ischial spines) is important for assessing progress in labor, but it's not the most crucial assessment immediately after epidural administration.
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Related Questions
Correct Answer is D
Explanation
A. Placenta accreta: Placenta accreta is a condition where the placenta attaches too deeply into the uterine wall. While this can be a concern, the client in this scenario has already given birth, so this may not be the highest priority at this moment.
B. Hard, painful uterine afterpains: Afterpains are common in the postpartum period, especially in women who have given birth to multiples. While they can be uncomfortable, they are generally expected and not considered a severe complication.
C. Postpartum psychosis: Postpartum psychosis is a serious mental health condition that can occur after childbirth. It is characterized by symptoms such as hallucinations, delusions, and severe mood disturbances. While it is a serious concern, it might not be the immediate priority in a client who has had a severe postpartum hemorrhage.
D. Disseminated intravascular coagulation (DIC): This is a life-threatening condition where there is widespread activation of clotting factors, leading to excessive blood clotting followed by bleeding. Given the history of severe postpartum hemorrhage, DIC is a significant concern, and prompt assessment and intervention are crucial.
Correct Answer is B
Explanation
A. Bleeding tendencies:
Bleeding tendencies are not typically a priority immediately after birth unless there is a specific indication. Newborns are not at immediate risk for bleeding unless there are underlying conditions.
B. Heat loss:
Heat loss is a significant concern for newborns. Maintaining an adequate temperature is crucial to prevent hypothermia, which can lead to complications.
C. Hypoglycemia:
While monitoring blood glucose is important in the newborn, it may not be the most immediate concern within the first minutes after delivery. Stabilizing the newborn's temperature and initiating breathing are usually higher priorities.
D. Fluid balance:
Fluid balance is essential, but the initial focus is often on establishing respirations and maintaining temperature. Fluids may be administered as needed based on the clinical assessment.
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