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. Isosorbide mononitrate is a nitrate medication used for angina and does not have significant interactions with albuterol.
B. Propranolol is a beta-blocker that can antagonize the effects of albuterol, potentially leading to decreased effectiveness in treating asthma symptoms.
C. Pantoprazole is a proton pump inhibitor used for gastrointestinal conditions and does not interact significantly with albuterol.
D. Montelukast is a leukotriene receptor antagonist used for asthma and allergies, but it does not have significant interactions with albuterol.
Correct Answer is ["1.5"]
Explanation
Convert the client's weight from pounds to kilograms by dividing by 2.2. 198 lb / 2.2 = 90 kg
Calculate the dose of filgrastim in micrograms by multiplying the client's weight in kilograms by the prescribed dose per kilogram. 90 kg x 5 mcg/kg = 450 mcg
Calculate the volume of filgrastim in milliliters by dividing the dose in micrograms by the concentration of the available solution. 450 mcg / 300 mcg/mL = 1.5 mL
Round the answer to the nearest tenth. The nurse should plan to give 1.5 mL of filgrastim with each dose.
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