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A client recently is planned for an epidural catheter in the second stage of labor.
Which assessments and interventions are necessary once an epidural catheter has been inserted? Select all that apply.

Have oxygen available in case of hypotension.

Maintain intravenous fluid administration.

Position the client supine for ease of monitoring.

Monitor fetal heart rate and labor progress per hospital protocol.

Check the bladder for distention every 2 hours.

Administer an oxytocin infusion to maintain the labor pattern.

Answer and Explanation

Correct Answer : A,B,D,E

Choice A rationale

Epidural anesthesia can cause vasodilation of peripheral blood vessels due to sympathetic blockade, which may lead to hypotension and subsequently reduced placental perfusion and fetal distress. Having oxygen ready is vital for prompt intervention if maternal hypotension occurs, maximizing oxygen delivery to both the mother and the fetus. The goal is to maintain optimal uteroplacental blood flow.

Choice B rationale

Maintaining intravenous (IV) fluid administration, typically a bolus of isotonic solution like normal saline or Lactated Ringer's, is crucial before and after epidural insertion. This volume expansion helps to counteract the peripheral vasodilation caused by the sympathetic block, thereby assisting in the prevention or minimization of maternal hypotension, which is a common side effect of regional anesthesia.

Choice C rationale

Positioning the client supine should be avoided after epidural insertion because the gravid uterus can compress the inferior vena cava, leading to supine hypotension syndrome. This reduces venous return, cardiac output, and uteroplacental blood flow. Clients should be maintained in a lateral or semi-Fowler's position with a wedge under the hip to displace the uterus.

Choice D rationale

Continuous monitoring of the fetal heart rate and uterine contractions is essential because maternal hypotension from the epidural can cause fetal hypoxia and bradycardia. Labor progress must also be closely monitored, as the epidural may affect the client's urge to push or necessitate changes in the timing or management of the second stage of labor.

Choice E rationale

Epidural anesthesia blocks the sensory and motor nerves, including those involved in the urinary reflex and the ability to void. Consequently, the client may develop bladder distention, which can impede fetal descent and cause discomfort. Checking the bladder every 2 hours (or per protocol) and performing straight catheterization if needed is vital.

Choice F rationale

Oxytocin infusion is used to induce or augment labor for hypotonic uterine dysfunction; however, it is not routinely administered following an epidural insertion solely to maintain the labor pattern. While an epidural can potentially slow labor, the decision to use oxytocin is based on the specific uterine contraction pattern and labor progression, not just the epidural itself.

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Correct Answer is C

Explanation

Choice A rationale

While the fetus at +4 station is deep in the pelvis, which can cause significant back discomfort due to the fetal occiput pressing on the maternal sacrum (occiput posterior position), the sudden drop in FHR (fetal heart rate) from 160 bpm (normal range 110-160 bpm) to 120 bpm is an acute concern unrelated to chronic back pain, though it could accompany intense contractions or pushing.

Choice B rationale

A fetal heart rate drop from 160 to 120 bpm, especially with the fetus at +4 station (meaning the presenting part is well past the ischial spines and close to delivery), may indicate a brief, benign event like a head compression (early deceleration) or potentially a more concerning one like a cord compression (variable deceleration), but does not automatically necessitate a cesarean birth unless the drop is persistent, severe, or indicative of fetal distress not resolving with interventions.

Choice C rationale

The fetal head being at +4 station (vertex presentation) is deep in the pelvis and the head is subject to significant compression during intense labor contractions. This compression can cause a temporary increase in intracranial pressure which stimulates the vagus nerve, resulting in a reflex deceleration of the heart rate (FHR drops) known as an early deceleration.

Choice D rationale

Meconium-stained amniotic fluid results from fetal gastrointestinal tract peristalsis and sphincter relaxation, often due to hypoxia or vagal stimulation. While the FHR drop could be related to hypoxia, the decreased heart rate itself is not directly from the meconium, which is a sign of a possible problem, not the cause of the acute FHR change.

A. Abdominal enlargement. B. Breast changes. C. Positive urine pregnancy test. D. Goodell sign. E. Fetal heart tones. F. Urinary frequency. G. Amenorrhea.

Correct Answer is ["B","F","G"]

Explanation

Choice A rationale

Abdominal enlargement is considered a probable sign of pregnancy, not presumptive, because conditions other than pregnancy (e.g., tumors, ascites) can cause it. Presumptive signs are those experienced by the woman that are subjective and least indicative of pregnancy, typically beginning earlier than probable signs like abdominal enlargement.

Choice B rationale

Breast changes, such as tenderness, fullness, or darkening of the areolae, are presumptive signs. These changes are subjective and are primarily caused by the elevated levels of estrogen and progesterone, which stimulate the mammary glands and increase vascularity, although other hormonal conditions can also cause them.

Choice C rationale

A positive urine pregnancy test detecting human chorionic gonadotropin (hCG) is classified as a probable sign of pregnancy. While highly suggestive, it is not considered a positive sign because elevated hCG can rarely be caused by conditions like a hydatidiform mole or certain tumors, which are not a viable pregnancy.

Choice D rationale

Goodell sign (softening of the cervix) is a probable sign of pregnancy. It is an objective change noted upon examination, usually around the fifth week, caused by increased vascularity and edema. Probable signs are objective, yet not definite, as they can be caused by other physiological changes.

Choice E rationale

Hearing fetal heart tones with a Doppler (around 10-12 weeks) or a fetoscope (later) is considered a positive sign of pregnancy. Positive signs are those directly attributable only to the presence of a fetus and cannot be confused with any other condition.

Choice F rationale

Urinary frequency is a presumptive sign often seen early in the first trimester. It is caused by hormonal changes and pressure from the enlarging uterus on the bladder. This symptom is subjective and also occurs in non-pregnant states, such as with a urinary tract infection or increased fluid intake.

Choice G rationale

Amenorrhea (absence of menstruation) is a presumptive sign of pregnancy. It is often the first and most classic indicator, but it is subjective and can also be caused by conditions such as stress, hormonal imbalances, or extreme weight changes, making it not definitive on its own.

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A client recently is planned for an epidural catheter in the second stage of labor. Which assessments and interventions are necessary once an epidural catheter has been inserted? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client whose fetus is at +4 station and in vertex presentation. The nurse notices the fetal heart rate drops from 160 to 120 beats per minute. The nurse plans and implements care with which consideration in mind?

Correct Answer is C

Explanation

What are presumptive signs of pregnancy that the nurse would expect when assessing a client at 10 weeks gestation. Select all that apply.

Correct Answer is ["B","F","G"]

Explanation

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A client recently is planned for an epidural catheter in the second stage of labor.
Which assessments and interventions are necessary once an epidural catheter has been inserted? Select all that apply.