A nurse is providing care to a client who is receiving an epidural block with an opioid analgesic.

Which of the following findings should the nurse monitor as a potential adverse effect of the medication?

Polyuria

Bilateral crackles

Hypotension

Hyperglycemia

Answer and Explanation

The Correct Answer is C

Choice A rationale
Polyuria, or excessive urination, is not typically associated with the administration of an epidural block with an opioid analgesic.
Choice B rationale
Bilateral crackles in the lungs can be a sign of a respiratory condition such as pneumonia or heart failure. However, they are not a common side effect of an epidural block with an opioid analgesic.
Choice C rationale
Hypotension, or low blood pressure, is a known side effect of epidural analgesia. This is due to the blockade of the sympathetic chain, which can contribute to hypotension. Therefore, it is important for the nurse to monitor the client’s blood pressure during the administration of an epidural block with an opioid analgesic.
Choice D rationale
Hyperglycemia, or high blood sugar, is not typically a side effect of an epidural block with an opioid analgesic. Hyperglycemia is more commonly associated with conditions such as diabetes.

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Correct Answer is A

Explanation

Choice A rationale
The instillation of antibiotic ophthalmic ointment is delayed to facilitate bonding between the newborn and the parent. Immediate skin-to-skin contact between the newborn and the parent has been shown to have several benefits, including stabilizing the newborn’s heart rate, temperature, and breathing, stimulating digestion, helping the newborn to sleep, promoting weight gain, and aiding in maternal attachment.
Choice B rationale
The newborn’s weight does not affect the timing of the instillation of antibiotic ophthalmic ointment.
Choice C rationale
Manifestations of infection in the newborn’s eyes would not be immediately apparent following birth, so this would not be a reason to delay the instillation of antibiotic ophthalmic ointment.
Choice D rationale
The mode of delivery, whether vaginal or cesarean, does not affect the timing of the instillation of antibiotic ophthalmic ointment.

A. Assist the client in pulling their knees toward their abdomen. B. Press firmly on the client’s suprapubic area. C. Apply pressure to the client’s fundus. D. Move the client onto their hands and knees.

Correct Answer is A

Explanation

In the event of shoulder dystocia during the second stage of labor, the provider may instruct the nurse to perform the McRoberts maneuver. This involves assisting the client in pulling their knees toward their abdomen. This position effectively flattens the sacrum, changes the angle of the pelvic inlet, and allows more room for the baby to pass through the birth canal.

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A nurse is providing care to a client who is receiving an epidural block with an opioid analgesic. Which of the following findings should the nurse monitor as a potential adverse effect of the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn immediately following birth. For which of the following reasons should the nurse delay the instillation of antibiotic ophthalmic ointment?

Correct Answer is A

Explanation

A nurse is caring for a client who is in the second stage of labor and is experiencing shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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A nurse is providing care to a client who is receiving an epidural block with an opioid analgesic.

Which of the following findings should the nurse monitor as a potential adverse effect of the medication?