A nurse is caring for a patient receiving epidural analgesia for pain during labor. Which of the following observations should be the nurse’s priority?
The patient’s blood pressure is 80/56 mm Hg.
The patient reports lower extremity weakness.
The patient’s temperature is 38.2°C (100.8 F).
The patient reports severe itching.
The Correct Answer is A
Choice A rationale
The patient’s blood pressure is significantly low, which could indicate hypotension, a serious side effect of epidural analgesia. This should be the nurse’s priority as it can lead to complications such as decreased perfusion to vital organs.
Choice B rationale
Lower extremity weakness can be a side effect of epidural analgesia, but it is not as immediately life-threatening as hypotension.
Choice C rationale
A slight increase in temperature may not be an immediate concern unless it continues to rise or is accompanied by other signs of infection.
Choice D rationale
Severe itching can be a side effect of epidural analgesia, but it is not as immediately life- threatening as hypotension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
An abnormal absolute neutrophil count in a preschooler should be reported to the healthcare provider immediately. Neutrophils are a type of white blood cell that play a key role in the body’s immune response. An abnormal count could indicate an infection, inflammation, or other serious health conditions.
Correct Answer is ["B","C"]
Explanation
Choice A rationale
Insulin glargine does not last for 3 to 6 hours. It is a long-acting insulin that has a duration of action up to 24 hours.
Choice B rationale
This is correct. Insulin glargine lasts for 18 to 24 hours. It is a long-acting insulin that provides a base level of insulin that keeps working for 24 hours or longer.
Choice C rationale
This is also correct. Insulin glargine lasts for 16 to 24 hours. It is a long-acting insulin that provides a base level of insulin that keeps working for 24 hours or longer.
Choice D rationale
Insulin glargine does not last for 6 to 10 hours. It is a long-acting insulin that has a duration of action up to 24 hours.
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