A nurse is reinforcing teaching with a client who has gestational hypertension about collecting a 24-hr urine specimen for protein. Which of the following statements should the nurse include in the teaching?

Rationale:

A. Tachycardia is not a common or direct adverse effect of epidural anesthesia itself. While a rapid heart rate may occur secondary to maternal anxiety or as a compensatory response to hypotension, it is not the primary physiological marker for epidural complications. Heart rate typically remains stable or may decrease slightly as pain is relieved and sympathetic activity is modulated.

B. Fever is a documented potential adverse effect associated with epidural anesthesia, particularly during labor. The exact mechanism is multifactorial, potentially involving altered thermoregulation, reduced heat dissipation due to sympathetic blockade, or a non-infectious inflammatory response. Clinicians must distinguish this pharmacological pyrexia from maternal infection to ensure appropriate neonatal and maternal management following the delivery.

C. Tachypnea, or an increased respiratory rate, is generally not associated with epidural anesthesia. In fact, if the anesthesia level rises too high, it can lead to respiratory depression or a decreased rate due to the blockade of intercostal muscle nerves. Effective epidural analgesia usually promotes a more relaxed, normal breathing pattern by successfully alleviating the physiological stress and hyperventilation caused by acute pain.

D. Hypertension is the opposite of the expected vascular response to epidural anesthesia. The local anesthetic typically causes a sympathetic blockade, leading to peripheral vasodilation and a significant risk of maternal hypotension rather than high blood pressure. Monitoring blood pressure is a critical nursing priority because decreased systemic vascular resistance can compromise placental perfusion and lead to fetal heart rate decelerations.

A) Incorrect- While notifying the provider might be necessary, addressing bladder distention takes precedence in this scenario.
B) Incorrect- Administering an analgesic might be indicated for pain relief, but addressing bladder distention is the priority.
C) Correct - Assisting the client to empty her bladder is the first action to take. A full bladder can prevent the uterus from contracting properly and can lead to excessive bleeding.
D) Incorrect- Monitoring perineal pads for clots is important but not the first action to take when bladder distention is present.