A client is receiving an epidural anesthesia during labor. Which observation is the most important adverse effect that the practical nurse (PN) should assess for following the administration of the epidural?
Maternal hypotension.
A vaginal hematoma.
A continuous headache.
Urinary retention.
The Correct Answer is A
A. Maternal hypotension is a significant adverse effect of epidural anesthesia that can lead to decreased uterine blood flow and fetal distress. Monitoring for hypotension is critical to ensure both maternal and fetal well-being.
B. While a vaginal hematoma is a potential complication, it is less immediately associated with the administration of epidural anesthesia compared to hypotension.
C. A continuous headache could indicate post-dural puncture but is less common and not the primary immediate concern compared to hypotension following an epidural.
D. Urinary retention can occur with epidural anesthesia, but maternal hypotension is a more urgent and significant immediate concern.
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Related Questions
Correct Answer is B
Explanation
A. Elevated blood glucose is not typically associated with Cheyne-Stokes respirations. It might indicate diabetes or hyperglycemia but does not relate to this specific pattern of breathing.
B. Cheyne-Stokes respirations are often observed when death is imminent or in severe cases of terminal illness. This breathing pattern is characterized by cycles of increasing and decreasing respirations, often seen in end-of-life care.
C. An allergic reaction might cause respiratory symptoms, but it is not specifically associated with Cheyne-Stokes respirations. Assessing for Cheyne-Stokes would be more relevant in terminal or serious conditions rather than acute allergic reactions.
D. Cheyne-Stokes respirations are not related to strenuous exercise. After exercise, normal changes in breathing patterns occur, but Cheyne-Stokes respirations are indicative of more severe conditions.
Correct Answer is D
Explanation
A. Determining if the spouse has medication allergies is unnecessary because the PN should not provide medication to anyone other than the patient. Medication administration policies are strict about who can receive medications and ensuring compliance with these policies is crucial for legal and safety reasons.
B. The PN cannot request medication for individuals who are not patients under their care, so this action does not follow hospital procedures. Medications must be administered through proper channels to ensure they are given safely and legally.
C. Giving medication from the nurse’s personal supply is a violation of hospital policy and professional ethics. All medications must be obtained through approved sources and administered according to prescribed orders for safety and legal reasons.
D. Explaining that medication can only be provided to clients ensures adherence to hospital policies and legal regulations. This action maintains professional boundaries and ensures that only those who are officially under care receive medication.
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