A nurse is caring for a client who is receiving epidural analgesia during labor. Which of the following findings is the nurse's first priority?

Temperature 38.2°C (100.8°F)

The client reports reduced sensation of the lower extremities.

The client reports generalized itching.

Blood pressure 80/52 mm Hg

Answer and Explanation

The Correct Answer is D

A: Elevated temperature during labor may be common and is not the nurse's first priority, especially when the client is receiving epidural analgesia, as it can be related to the stress of labor or other factors.
B: Reduced sensation of the lower extremities is an expected effect of epidural analgesia, and it is not the nurse's first priority unless it leads to complications such as motor weakness or respiratory distress.
C: Generalized itching is a common side effect of epidural analgesia due to opioids, and it can be managed with interventions such as antihistamines. However, it is not the nurse's first priority unless it is severe or accompanied by other concerning symptoms.
D: Epidural analgesia can cause vasodilation and decrease the client's blood pressure, which can lead to hypotension. Hypotension can be detrimental to both the mother and the baby and requires immediate attention to prevent complications. Therefore, the nurse's first priority is to address the low blood pressure.

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Correct Answer is A

Explanation

Choice A: The first priority assessment finding to report to the provider is contractions lasting 2 minutes and with no rest between contractions. Prolonged contractions without adequate rest can lead to uterine hyperstimulation and fetal distress, potentially compromising the wellbeing of both the client and the baby. The provider needs to be informed immediately for further

evaluation and intervention.

Choice B: Pressure on the perineum and the desire to bear down indicate that the client is experiencing the urge to push, which is expected during the second stage of labor, not during the active phase of the first stage. It is not the first priority to report.

Choice C: Clear fluid discharge from the vagina can indicate rupture of membranes, but it is not an immediate concern unless the fluid is meconiumstained or there are other signs of fetal distress.

Choice D: Passage of a bloodtinged mucous plug (also known as "bloody show") is a common sign that labor is approaching, but it is not an immediate concern unless there are other signs of labor progression or complications. It is not the first priority to report.

A. "Change the client's position to left lateral and observe for resolution of the decelerations." B. "Administer oxygen at 10 L/min via a nonrebreather mask and observe for resolution of the decelerations." C. "Apply a fetal scalp electrode and observe for resolution of the decelerations." D. "Increase the rate of the IV infusion and observe for resolution of the decelerations."

Correct Answer is A

Explanation

Choice A: Late decelerations in the fetal heart rate are often associated with uteroplacental insufficiency, and one of the first interventions is to improve uterine blood flow by changing the client's position. Placing the client in a left lateral position can help relieve pressure on the vena cava and improve blood flow to the placenta and the baby.

Choice B: Administering oxygen is a correct intervention for late decelerations, but it should follow the position change. Oxygen administration helps increase oxygen levels in the maternal blood, which can improve fetal oxygenation.

Choice C: Applying a fetal scalp electrode can provide continuous fetal heart rate monitoring, but it does not address the immediate concern of late decelerations. Position change and oxygen administration should be the priority.

Choice D: Increasing the rate of the IV infusion might not have an immediate effect on resolving late decelerations. Position change and oxygen administration should be the initial interventions.

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A nurse is caring for a client who is receiving epidural analgesia during labor. Which of the following findings is the nurse's first priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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