A nurse is assessing a client who is in labor and is receiving epidural anesthesia. Which of the following findings should the nurse identify as the priority?
Urinary retention
Leg weakness
Hypotension
Temperature 39°C (102.2°F)
The Correct Answer is C
A. Urinary retention: While urinary retention can be a complication of epidural anesthesia, it is not the priority finding in this scenario. The priority is to address potential complications that can lead to maternal or fetal compromise.
B. Leg weakness: Leg weakness can occur as a side effect of epidural anesthesia but is not the priority finding in this scenario unless it is severe and compromises the client's ability to
mobilize or push during labor.
C. Hypotension: Hypotension is a common complication of epidural anesthesia due to sympathetic blockade, which can lead to decreased venous return and subsequent maternal
hypotension. Maternal hypotension can compromise uteroplacental perfusion, leading to fetal distress. Therefore, addressing hypotension promptly is the priority to prevent adverse maternal and fetal outcomes.
D. Temperature 39°C (102.2°F): While fever should be monitored and addressed, it is not the priority finding in this scenario unless it indicates an infection, which would require further assessment and intervention. However, maternal hypotension poses a more immediate risk to both the mother and the fetus during labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Respiratory rate: While propranolol can potentially affect respiratory function in individuals with certain respiratory conditions, such as asthma, assessing the respiratory rate is not typically a priority assessment before administering propranolol.
B. HR rate: Propranolol is a beta-blocker that primarily affects heart rate and blood pressure.
Therefore, assessing the heart rate (HR) is crucial prior to administering propranolol, as it can cause bradycardia and heart block.
C. Pain level: Propranolol is not typically associated with pain modulation or analgesic effects.
Assessing pain level may be relevant for other medications or conditions but is not specifically related to propranolol administration.
D. Temperature: Propranolol does not typically affect body temperature, and assessing temperature is not typically necessary before administering propranolol.
Correct Answer is B
Explanation
A. Bruxism: Bruxism, or teeth grinding, is a potential adverse effect of citalopram but is generally less severe than confusion. While it should be monitored and reported if severe or persistent, it is not typically considered a priority adverse effect.
B. Confusion: Confusion can indicate a serious adverse reaction or complication, such as serotonin syndrome, which is a potentially life-threatening condition associated with the use of selective serotonin reuptake inhibitors (SSRIs) like citalopram. Therefore, confusion is the priority adverse effect to report to the provider.
C. Insomnia: Insomnia is a common side effect of citalopram and other SSRIs but is generally less severe than confusion. It should be monitored and reported if severe or persistent, but it is not typically considered a priority adverse effect.
D. Weight loss: Weight loss can occur as a side effect of citalopram but is generally less severe than confusion. It should be monitored and reported if excessive or rapid, but it is not typically considered a priority adverse effect.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today