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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Polycystic ovarian syndrome is a hormonal disorder common among women of reproductive age. While it can lead to several complications, it does not significantly increase the risk of sepsis.
Choice B rationale
Cancer and certain treatments for cancer can weaken the immune system, increasing the risk of infections that could lead to sepsis.
Choice C rationale
Kallmann’s syndrome is a genetic condition that affects the production of a hormone involved in sexual development. It does not significantly increase the risk of sepsis.
Choice D rationale
Addison’s disease affects the adrenal glands and can disrupt the balance of hormones in the body, but it does not significantly increase the risk of sepsis.
Correct Answer is B
Explanation
Choice A rationale
Lower quadrant pain is a common symptom of many conditions, including ectopic pregnancy. However, it does not specifically indicate the presence of blood in the peritoneum.
Choice B rationale
Cullen’s sign, which is the appearance of bruising in the skin around the umbilicus, is a sign of blood in the peritoneum. It can occur in conditions such as a ruptured ectopic pregnancy.
Choice C rationale
Goodell’s sign is a softening of the cervix that typically occurs early in pregnancy. It does not indicate the presence of blood in the peritoneum.
Choice D rationale
Chadwick’s sign is a bluish discoloration of the cervix, vagina, and labia that occurs in early pregnancy. It does not indicate the presence of blood in the peritoneum.
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