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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale

While it’s important to communicate any concerns to the primary care provider, this response does not provide immediate reassurance or information to the mother about her newborn’s crossed eyes.

Choice B rationale

This is the most therapeutic response. It provides factual information that can reassure the mother. Newborns often lack the muscle control to regulate eye movement, which can result in temporary crossing of the eyes.

Choice C rationale

Taking the baby to the nursery for further examination may cause unnecessary worry for the mother. It’s better to provide reassurance and education first.

Choice D rationale

This response may cause unnecessary worry for the mother. Strabismus, or constant misalignment of the eyes, is not typically seen in newborns and would require treatment. However, temporary crossing of the eyes due to lack of muscle control is normal. Propranolol Propranolol Explore

Correct Answer is ["2"]

Explanation

Step 1: Determine the amount of medication needed. The order is for 20 mEq of potassium chloride. The available amount is 10 mEq/mL.

Step 2: Calculate the volume of medication to administer. Volume = Ordered dose ÷ Available concentration Volume = 20 mEq ÷ 10 mEq/mL = 2 mL So, the nurse should administer 2 mL of potassium chloride suspension.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a new mother who is worried about her newborn’s crossed eyes. What is a therapeutic response from the nurse?

Correct Answer is B

Explanation

A nurse is about to administer a daily dose of potassium chloride 20 mEq suspension orally. The available amount is potassium chloride suspension 10 mEq/mL. How many mL should the nurse administer?

Correct Answer is ["2"]

Explanation

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