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. Administer oxygen via facemask: Oxygen administration is generally a step in managing fetal distress. However, when dealing with variable decelerations, the initial action involves repositioning the mother to alleviate potential cord compression, as variable decelerations are often due to compression of the umbilical cord.
B. Turn off the oxytocin infusion: If variable decelerations persist despite repositioning, it might be necessary to discontinue the oxytocin (Pitocin) infusion temporarily. Oxytocin can cause or exacerbate uterine hyperstimulation, which can contribute to fetal distress.
C. Assess cervical dilatation: Assessing cervical dilatation might be a part of the overall assessment but might not directly address the immediate issue of variable decelerations. However, it's essential to monitor the progress of labor as part of the broader assessment.
D. Change the client's position: This is the recommended first action for variable decelerations. Repositioning the mother, such as moving her to a lateral or knee-chest position, can relieve potential cord compression and improve fetal oxygenation.
Correct Answer is A
Explanation
A. Strawberries:
Strawberries contain a moderate amount of folic acid, providing a good alternative source for the client. While not as high as some vegetables, they still offer a reasonable amount of this essential nutrient. This could be a suitable option considering the client's dislike for green leafy vegetables and allergy to soy.
B. Collard greens:
Collard greens are an excellent source of folic acid. However, since the client dislikes green leafy vegetables, recommending collard greens might not align with her preferences.
C. Whole milk:
Whole milk doesn't contain significant amounts of folic acid. While it's a source of other nutrients, it isn't a primary choice for obtaining folic acid.
D. Yogurt:
Similar to whole milk, yogurt doesn't contain a substantial amount of folic acid. While it offers various health benefits due to its probiotics and nutrients, it's not a significant source of folic acid.
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