A nurse is assessing a client who is in labor and has received epidural analgesia. Which of the following findings should the nurse recognize and document as an adverse effect of epidural analgesia?

Hypotension.

Polyuria.

Fetal heart rate 152/min.

Maternal temperature of 37.4° C (99.4° F).

Answer and Explanation

The Correct Answer is A

Choice A rationale:
Hypotension is a common adverse effect of epidural analgesia due to the blockage of sympathetic nerve fibers, which can lead to vasodilation and decreased cardiac output.
Choice B rationale:
Polyuria is not typically associated with epidural analgesia. It could be related to other factors such as fluid administration or underlying medical conditions.
Choice C rationale:
A fetal heart rate of 152/min is within the normal range (110-160 beats/min) and is not an adverse effect of epidural analgesia.
Choice D rationale:
A maternal temperature of 37.4° C (99.4° F) is within the normal range (36.1° C to 37.2° C or 97° F to 99° F) and is not an adverse effect of epidural analgesia.

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Correct Answer is B

Explanation

Choice A rationale:
The amount of amniotic fluid around the fetus is determined by an ultrasound, not an indirect Coombs’ test.
Choice B rationale:
The indirect Coombs’ test is used to detect Rh-positive antibodies in the mother’s blood.
Choice C rationale:
The risk of hypoglycemia in the newborn is not determined by the indirect Coombs’ test.
Choice D rationale:
Blood flow in the fetus and placenta is studied using Doppler ultrasound, not an indirect Coombs’ test.

A. Give oxytocin 20 units IV bolus. B. Perform a fundal massage. C. Assess for abdominal tenderness. D. Obtain serial hemoglobin and hematocrit.

Correct Answer is D

Explanation

Choice A rationale:
Giving oxytocin 20 units IV bolus is incorrect. Oxytocin is used to stimulate uterine contractions, not to stop bleeding.
Choice B rationale:
Performing a fundal massage is incorrect. This is done to stimulate uterine contractions, not to stop bleeding.
Choice C rationale:
Assessing for abdominal tenderness is incorrect. This is not a priority action when a client is exhibiting a large amount of vaginal bleeding.
Choice D rationale:
Obtaining serial hemoglobin and hematocrit is correct. These lab tests will help determine the extent of blood loss and guide treatment.

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A nurse is assessing a client who is in labor and has received epidural analgesia. Which of the following findings should the nurse recognize and document as an adverse effect of epidural analgesia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client about the purpose of her upcoming indirect Coombs' test. Which of the following statements should the nurse include in the teaching?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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