A nurse is caring for a client who is receiving epidural analgesia during labor.Which of the following symptoms should the nurse report to the physician?
Temperature 37.8°C (100.3°F).
Generalized itching.
The client reports weakness of the lower extremities.
Fetal bradycardia.
The Correct Answer is D
Choice A rationale
A temperature of 37.8°C (100.3°F) is a low-grade fever that does not typically indicate a serious issue in the context of epidural analgesia during labor. It should be monitored, but it's not immediately concerning.
Choice B rationale
Generalized itching can be a common side effect of epidural analgesia due to the opioids used. It should be monitored and managed, but it does not typically require immediate physician notification.
Choice C rationale
Weakness of the lower extremities can be expected with epidural analgesia as it causes a loss of sensation and muscle control. This should be monitored, but it is not typically an emergency.
Choice D rationale
Fetal bradycardia is a serious concern that must be reported to the physician immediately. It can indicate fetal distress and requires urgent evaluation and intervention to ensure the well-being of the baby. .
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Related Questions
Correct Answer is A
Explanation
Choice A rationale
Reassuring the patient that she will deliver vaginally is inappropriate and could be misleading, especially if there are complications such as placental abruption or severe pre-eclampsia, which may necessitate a cesarean delivery for the safety of the mother and baby.
Choice B rationale
Inserting an indwelling Foley catheter is a standard procedure to monitor urine output and kidney function, especially in cases of pre-eclampsia, where accurate monitoring of fluid balance is crucial.
Choice C rationale
Initiating IV therapy with Lactated Ringer's solution is important to maintain maternal hydration and electrolyte balance, especially if the client is experiencing blood loss and is at risk of hypovolemia.
Choice D rationale
Monitoring the fetal heart tracing is essential to assess the baby's well-being. Continuous fetal monitoring helps detect signs of fetal distress, allowing for timely interventions to ensure the safety of both mother and baby.
Correct Answer is D
Explanation
Choice A rationale
Observing the perineum for signs of crowning is important, but it doesn’t address the immediate need to manage the client’s urge to push. By the time crowning is visible, delivery is imminent, and the urge to push should have been managed earlier.
Choice B rationale
Helping the client to the bathroom to void might relieve some pressure but is not the immediate priority when the client feels the urge to push. Voiding can wait until contractions are managed.
Choice C rationale
Assisting the client into a supine position is not ideal for managing the urge to push. A supine position can increase discomfort and does not facilitate optimal delivery dynamics.
Choice D rationale
Assisting the client with quick shallow breathing helps manage the urge to push and prevents premature pushing, reducing the risk of cervical injury and aiding controlled delivery.
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