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
Choice A rationale
Telling the patient that this is the medication their doctor wants them to take does not address the patient’s concern about the color of the pill.
Choice B rationale
While it’s true that the same medication can sometimes come in different colors, this response does not confirm that the orange pill is the correct medication for the patient.
Choice C rationale
Checking the medication order again is the best response. This will ensure that the patient is receiving the correct medication.
Choice D rationale
Explaining the purpose of the medication does not address the patient’s concern about the color of the pill.
Correct Answer is D
Explanation
Choice A rationale
Taking ibuprofen with aspirin is not typically recommended without a doctor’s advice. Both are nonsteroidal anti-inflammatory drugs (NSAIDs), and taking them together increases the risk of side effects such as stomach bleeding.
Choice B rationale
Ibuprofen is not used for stroke prevention. Aspirin, not ibuprofen, is often used for this purpose because of its antiplatelet effect.
Choice C rationale
Crushing sustained-release forms of medication is generally not recommended because it can lead to a rapid release and absorption of the drug, which increases the risk of side effects.
Choice D rationale
Taking ibuprofen with food is often recommended to reduce the risk of stomach upset.
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