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 A
Explanation
A. The correct order is
- wipe off tops of insulin vials with alcohol sponge.
- draw back amount of air into the syringe that equals total dose.
- inject air equal to NPH dose into NPH vial. ...
- air equal to regular dose into regular vial.
- invert regular insulin bottle and withdraw regular insulin dose.
- without adding more air into NPH vial, carefully withdraw NPH dose
B. Withdraw the regular insulin from the vial: This step should occur after injecting air into the regular insulin vial. The nurse should draw up the regular insulin before drawing up the NPH
insulin.
C. Inject air into the regular insulin vial: Inject air into the regular insulin vial is not thecorrect first step to avoid contamination of the clear insulin with cloudy insulin..
D. Withdraw the NPH insulin from the vial: This step should occur after withdrawing the regular insulin. The nurse should draw up the NPH insulin after drawing up the regular insulin to ensure the correct sequence and dosage.
Correct Answer is C
Explanation
A. "You will be weighed twice a week while receiving TPN": While weight monitoring may be part of the client's overall care plan, it is not specifically related to TPN administration.
Therefore, this statement is not a priority for inclusion in the teaching.
B. "Your blood sugar will be checked once a day": Blood sugar monitoring may be necessary for clients receiving TPN, especially if they have diabetes or are at risk of hyperglycemia. However, the frequency of monitoring may vary depending on individual factors and is not universally applicable. Therefore, this statement may or may not be accurate for this client and should not be included in the teaching.
C. "You will have a central line placed to receive TPN": TPN solutions are administered through a central venous catheter to ensure adequate and safe delivery of nutrients directly into the bloodstream. Therefore, informing the client about the need for a central line is essential for TPN administration and should be included in the teaching.
D. "Your intake and output will be measured every 2 days": While monitoring intake and output is important for assessing fluid balance and renal function, the frequency of measurement may vary depending on the client's condition and institutional protocols. Therefore, this statement
may or may not be accurate for this client and should not be a priority for inclusion in the teaching.
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