A nurse is caring for a 26-year-old female client who is in active labor in the labor and delivery unit.
The client has requested epidural anesthesia, and it has been administered to manage her pain during labor. The nurse is now monitoring her condition closely.
Fetal decelerations
Reports of pain
Nausea
Dizziness
Hypotension
Difficulty breathing
Correct Answer : A,E,F
Choice A rationale: Fetal decelerations require immediate action because they indicate potential fetal distress. Continuous fetal monitoring is essential to assess the fetus's well-being, and any signs of distress must be addressed promptly to ensure a safe delivery.
Choice E rationale: Hypotension is a common side effect of epidural anesthesia and can lead to decreased blood flow to the fetus. Immediate intervention, such as administering IV fluids or medications, is necessary to stabilize the mother's blood pressure and ensure adequate fetal perfusion.
Choice F rationale: Difficulty breathing is a critical sign that may indicate a severe reaction to the epidural anesthesia or other complications. Immediate assessment and intervention are required to ensure the mother's respiratory status is stable and to address any underlying issues.
Choice B rationale: Reports of pain, while important, do not require immediate emergency action compared to the other findings. Pain management should be adjusted accordingly, but it does not pose an immediate threat to the mother or fetus.
Choice C rationale: Nausea, while uncomfortable, is a common side effect of epidural anesthesia and does not require immediate emergency intervention. It can be managed with antiemetic medications.
Choice D rationale: Dizziness can be a side effect of epidural anesthesia or hypotension, but it is not as critical as the other findings that require immediate emergency attention. It should be monitored and addressed as part of overall care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Reporting the client's jaw pain to the healthcare provider is crucial because jaw pain is a potential symptom of osteonecrosis of the jaw (ONJ), a rare but serious side effect of bisphosphonates like alendronate. ONJ involves the death of bone tissue in the jaw, leading to significant complications. Early intervention and management are essential to prevent further deterioration and address any underlying issues.
Choice B rationale
Determining how the client is administering the medication is important but not the immediate priority when addressing jaw pain, which could indicate a serious complication. Ensuring proper administration can prevent future issues but does not address the immediate concern of potential ONJ.
Choice C rationale
Advising the client to gargle with warm salt water twice daily may provide temporary relief from minor oral discomfort but is not appropriate for addressing potential osteonecrosis of the jaw. This suggestion does not address the underlying cause of jaw pain in a client taking bisphosphonates.
Choice D rationale
Confirming that jaw pain is a common symptom of osteoporosis is incorrect. While musculoskeletal pain can be associated with osteoporosis, jaw pain in a client taking alendronate may indicate osteonecrosis of the jaw, a serious condition requiring prompt medical attention.
Correct Answer is ["A","C","D"]
Explanation
The correct answers are Choices A, C, and D.
Choice A rationale: Encouraging the client to increase physical activity and engage with peers is appropriate as it helps prevent deconditioning, improves cardiovascular health, and promotes mental well-being. Physical activity can also improve muscle strength, mobility, and overall quality of life.
Choice B rationale: Suggesting the client remain in bed to avoid unnecessary exertion is incorrect. Prolonged bed rest can lead to muscle atrophy, pressure injuries, and decreased cardiovascular function. The client should be encouraged to mobilize as tolerated to maintain functional abilities.
Choice C rationale: Teaching the caregiver how to monitor for signs of infection in pressure injuries is crucial because the client has stage II pressure injuries that need careful monitoring and management to prevent complications such as infection. Education on signs of infection, proper wound care, and prevention strategies is essential.
Choice D rationale: Assisting the client in using the restroom to avoid incontinence is appropriate as it respects the client's preference for toileting, reduces the risk of skin breakdown, and promotes dignity. Helping the client maintain continence and proper hygiene is important for comfort and overall health.
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