A woman in labor has just received an epidural block.
The most important nursing intervention is to:
Monitor the maternal blood pressure for possible hypertension.
Monitor the maternal pulse for possible bradycardia.
Monitor the fetus for possible tachycardia.
Limit parenteral fluids.
The Correct Answer is B
Choice A rationale
Hypertension is not a common side effect of epidural blocks; instead, hypotension is more likely due to vasodilation. Monitoring for hypertension is not the most important intervention.
Choice B rationale
Bradycardia is a potential side effect of epidural blocks due to sympathetic blockade. Monitoring the maternal pulse for bradycardia ensures timely intervention if this side effect occurs.
Choice C rationale
Epidural blocks do not typically cause fetal tachycardia. Monitoring the fetus for tachycardia is not the primary nursing intervention following epidural administration.
Choice D rationale
Limiting parenteral fluids is not advised after an epidural block as fluids are essential to counteract potential hypotension. Fluid management is crucial to maintain maternal and fetal hemodynamics.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Mild contractions and minimal cervical dilation suggest false labor. Administering a sedative helps the patient rest and wait for true labor onset. Sedatives can include sleep-inducing medications.
Choice B rationale
Cesarean birth is not indicated for a primigravida with mild contractions and minimal cervical dilation. This intervention is reserved for more serious obstetric complications.
Choice C rationale
Extended observation is unnecessary for mild contractions and unchanged cervical status. It is more appropriate for patients showing signs of true labor or complications.
Choice D rationale
True labor onset requires regular, increasing intensity contractions and cervical changes. Discharging the patient allows her to await true labor onset at home comfortably.
Correct Answer is B
Explanation
Choice A rationale
The cervix is measured in dilation, not effacement, in centimeters. Effacement is expressed in percentage, indicating the thinning of the cervix.
Choice B rationale
The cervix is 3 cm dilated, 30% effaced, and the presenting part is 2 cm above the ischial spines. This assessment provides a clear status of labor progress.
Choice C rationale
The presenting part being below the ischial spines would be recorded with a positive station, indicating descent into the pelvis, unlike this assessment.
Choice D rationale
The cervix is assessed for dilation in centimeters and effacement in percentage, with station indicating the relationship to the ischial spines.
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