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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Correct Answer is D
Explanation
Choice A rationale
Infection risk is generally higher postpartum rather than during the third stage of labor.
Choice B rationale
Fetal hypoxia is a concern during labor, but the third stage is more focused on delivery of the placenta.
Choice C rationale
Deep vein thrombosis is a longer-term postpartum concern, not specifically high risk in the third stage of labor.
Choice D rationale
Incomplete delivery of the placenta can lead to hemorrhage and is a primary concern in the third stage of labor.
Correct Answer is D
Explanation
Choice A rationale
The first stage of labor, transition phase, is characterized by rapid cervical dilation from 7 cm to 10 cm, intense contractions, and strong desire to push. This client's cervix is only 3 cm dilated, indicating that she is not in the transition phase.
Choice B rationale
The second stage of labor, active phase, is the period from full cervical dilation to the birth of the baby. This stage involves active pushing and the descent of the baby through the birth canal. This client's cervix is not fully dilated, so she cannot be in the second stage.
Choice C rationale
The second stage of labor, latent phase, does not exist. The latent phase is part of the first stage of labor, not the second stage. This choice is incorrect because it misrepresents the stages of labor.
Choice D rationale
The first stage of labor, latent phase, is characterized by regular contractions, cervical effacement, and dilation up to 4 cm. This client's cervix is 80% effaced and 3 cm dilated, indicating that she is in the latent phase of the first stage of labor.
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