A nurse is caring for a client who is receiving an epidural for continuous labor analgesia.
Which of the following findings should indicate to the nurse that the treatment is effective?
The client reports slight pressure with contractions.
The client has bladder distention.
The client's systolic blood pressure decreases by 20 mm Hg.
The client is unable to move their legs or feet.
The Correct Answer is A
Choice A rationale
The primary goal of epidural analgesia is to provide effective pain relief while allowing the client to maintain some sensation, particularly pressure, which indicates the epidural is blocking nociceptive pain signals effectively without completely eliminating proprioceptive awareness. This selective blockade allows the client to feel contractions, facilitating pushing efforts, while minimizing pain perception by blocking transmission of pain impulses via spinal nerves.
Choice B rationale
Bladder distention is a common side effect of epidural analgesia, resulting from the blockade of parasympathetic nerve fibers innervating the bladder, which can impair the micturition reflex. While it indicates the epidural's systemic effect, it is an adverse effect requiring intervention, such as catheterization, rather than a direct indicator of effective pain management.
Choice C rationale
A decrease in systolic blood pressure by 20 mm Hg, or more, is a common adverse effect of epidural analgesia, caused by sympathetic blockade, leading to vasodilation and subsequent peripheral pooling of blood. While it demonstrates the systemic absorption and action of the anesthetic, it signifies a complication requiring management, not an indicator of effective pain relief for labor.
Choice D rationale
Inability to move legs or feet suggests a dense motor blockade, which can occur with epidural analgesia but is not the desired outcome for labor. While a degree of motor weakness may be present, complete motor paralysis can hinder effective pushing during the second stage of labor and is usually avoided to allow for maternal participation in the birth process.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Depression is a common mental health condition and is not a contraindication for the use of a copper intrauterine device (IUD). The copper IUD is a non-hormonal contraceptive method, meaning it does not release hormones that could potentially interact with or exacerbate symptoms of depression. Therefore, it is a safe option for individuals with this condition.
Choice B rationale
Diabetes mellitus, when well-controlled, is not a contraindication for the use of a copper IUD. The copper IUD does not affect blood glucose levels or insulin sensitivity, making it a suitable contraceptive option for individuals with diabetes. Hormonal methods might require more careful consideration, but copper IUDs are generally safe.
Choice C rationale
Cholelithiasis, or gallstones, is a condition affecting the gallbladder and bile ducts. It is not a contraindication for the use of a copper IUD. The copper IUD's mechanism of action is local, primarily affecting the uterine environment, and does not involve systemic hormonal changes that would impact gallbladder function.
Choice D rationale
Dysmenorrhea, or painful menstruation, is a significant contraindication for the use of a copper IUD. The copper IUD is known to increase menstrual bleeding and cramping, which can worsen pre-existing dysmenorrhea. This potential exacerbation of symptoms can lead to client dissatisfaction and discontinuation of the method.
Correct Answer is C
Explanation
Choice A rationale
Assessing blood pressure twice daily is insufficient for a client with preeclampsia postpartum. Preeclampsia can worsen or manifest postpartum, necessitating more frequent monitoring, typically every 4 hours or more depending on the severity, to detect changes indicating progression or resolution of the condition and guide timely intervention.
Choice B rationale
Administering an IV bolus of lactated Ringer's could exacerbate fluid overload in a client with preeclampsia, as these clients often have compromised renal function and increased extracellular fluid. Fluid administration should be carefully managed to avoid pulmonary edema, and boluses are generally avoided unless hypovolemia is clearly indicated.
Choice C rationale
Assessing for edema is crucial postpartum for a client with preeclampsia. Preeclampsia is characterized by widespread endothelial dysfunction, leading to increased vascular permeability and fluid shifts into interstitial spaces. Monitoring edema, particularly in the face and extremities, helps evaluate fluid status and assess the resolution or persistence of the preeclamptic state.
Choice D rationale
Obtaining a prescription for misoprostol is not indicated for the management of preeclampsia without severe features postpartum. Misoprostol is a prostaglandin analog primarily used for cervical ripening, labor induction, or postpartum hemorrhage management due to its uterotonic properties, not for the direct management of hypertension or other preeclamptic symptoms.
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