A nurse is caring for a client who received epidural analgesia during labor and is 4 hr postpartum. Which of the following client reports should the nurse address first?
Tingling in her legs
Abdominal cramps
Itching
Inability to void
The Correct Answer is D
Epidural analgesia during labor can cause temporary bladder dysfunction, which may result in an inability to void. This is due to the epidural medication affecting the nerves that control the bladder. If the client is unable to void, it can lead to bladder distention, which can be uncomfortable for the client and increase the risk of infection.
Tingling in her legs, abdominal cramps, and itching are common side effects of epidural analgesia, and can be addressed after the client's inability to void is addressed. The nurse can provide the client with education on these side effects and reassurance that they are typically temporary and should resolve on their own.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nonstress test is a screening tool that assesses fetal well-being. It is performed by monitoring the fetal heart rate (FHR) and uterine contractions (UC) while the client is at rest. The test is considered reactive if there are two or more accelerations of the FHR that reach a certain level above the baseline and last for at least 15 seconds over a 20-min period.
The presence of irregular contractions that are not felt by the client is a finding that is concerning because it could be a sign of uterine hyperstimulation, which can lead to fetal distress. Further diagnostic testing may be needed to assess fetal well-being in this situation.
Option A indicates that the client felt fetal movements during the testing period. This is a reassuring finding because fetal movements are a sign of fetal well-being.
Option B indicates that there were no late decelerations in the FHR with uterine contractions. This is a reassuring finding because late decelerations are a sign of fetal compromise.
Option C indicates that there was an acceleration of the FHR in response to fetal movement. This is a reassuring finding because it indicates that the fetus is capable of responding to stimuli.
Correct Answer is D
Explanation
Magnesium sulfate is a medication commonly used to treat preeclampsia, a pregnancy-related condition characterized by high blood pressure and damage to other organ systems, such as the kidneys. However, magnesium sulfate can also cause adverse reactions, and the nurse should be aware of these reactions.
The nurse should recognize that a urine output of 20 mL/hr is a manifestation of an adverse reaction to magnesium sulfate, as magnesium sulfate can cause decreased urine output, which can lead to dehydration and electrolyte imbalances. The nurse should promptly report this finding to the provider, as it may require immediate intervention.
Option A is incorrect because hypertension is a symptom of preeclampsia, not an adverse reaction to magnesium sulfate.
Option B is also incorrect because hyperglycemia is not an adverse reaction to magnesium sulfate.
Option C is also incorrect because a respiratory rate of 16/min is within the normal range.
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