Scenario:
A nurse is caring for a 26-year-old gravida 2 para 1 female client in the labor and delivery unit.

Exhibits
The client receiving epidural anesthesia would be at risk for developing
dropdown
due to
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E"}

Epidural anesthesia can cause vasodilation and a resultant drop in blood pressure, hence the importance of close monitoring and IV fluid administration to maintain blood pressure levels.

Risk Factors:

Peripheral vasodilation: This is related to the relaxation of blood vessels, which can lead to a drop in blood pressure (hypotension). It is not a direct risk on its own but a cause of hypotension.
Hypotension: This is the correct answer. Epidural anesthesia can cause a significant drop in blood pressure due to vasodilation.
Urinary retention: This can occur with epidural anesthesia as the sensation to urinate may be diminished, causing the bladder to fill and potentially lead to bladder distention and discomfort.
Fluid overload: This is less commonly associated with epidural anesthesia. It is typically related to excessive intravenous fluid administration.

Causes:

Inadequate pain relief: This would not directly cause the issues mentioned above but would indicate that the epidural is not effectively managing the client's pain.
Decreased fetal heart rate: This can be a consequence of maternal hypotension, which reduces blood flow to the placenta.
Full urinary bladder: This can be a result of urinary retention due to the effects of the epidural, but it is not a direct cause of hypotension.
Inability to push: This can occur with epidural anesthesia as it may decrease the ability to feel contractions and effectively push during delivery, but it is not related to hypotension.

Nursing Test Bank

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Correct Answer is A

Explanation

Choice A rationale

Asking the client to describe the pain is the most effective way to assess the quality of pain. This approach allows the client to provide specific details about their pain experience, including the type, intensity, and characteristics, which are essential for accurate pain management.

Choice B rationale

Identifying effective pain relief measures is important but does not directly assess the quality of pain. This step is more focused on treatment rather than the initial assessment of pain quality.

Choice C rationale

Observing body language and movement can provide additional information about the pain but is not as reliable as directly asking the client. Nonverbal cues should supplement, not replace, the client's verbal report.

Choice D rationale

Providing a numeric pain scale helps quantify the intensity of pain but does not assess the quality. Quality assessment requires a descriptive approach to understand the nature of the pain fully.

A. Measure and discard residual gastric contents before feeding. B. Use the syringe plunger to push formula at a rate of 5 mL per minute. C. Hold the infant with head and shoulders slightly elevated. D. Microwave refrigerated formula to room temperature.

Correct Answer is C

Explanation

Choice A rationale

Measuring and discarding residual gastric contents before feeding is generally avoided in infants because it can disrupt gastrointestinal function and increase the risk of aspiration. Instead, monitoring for signs of intolerance or high residuals through clinical observation is preferred.

Choice B rationale

Using the syringe plunger to push formula at a rate of 5 mL per minute is inappropriate because it can create excessive pressure, leading to discomfort, aspiration, or injury to the gastrointestinal tract. Gravity feeding or using an appropriate pump at a controlled rate is safer.

Choice C rationale

Holding the infant with head and shoulders slightly elevated during feeding is recommended. This position helps to prevent aspiration by ensuring that the formula flows smoothly through the esophagus and into the stomach, reducing the risk of regurgitation.

Choice D rationale

Microwaving refrigerated formula to room temperature is unsafe because microwaving can create hot spots in the formula, posing a burn risk to the infant. It is safer to warm the formula by placing the bottle in warm water and ensuring an even temperature.

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Scenario: A nurse is caring for a 26-year-old gravida 2 para 1 female client in the labor and delivery unit. Exhibits The client receiving epidural anesthesia would be at risk for developing dropdown due to dropdown.

Nursing Test Bank

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A client with metastatic bone cancer is requesting pain medication. Which approach should the nurse use to assess the quality of the client's pain?

Correct Answer is A

Explanation

The nurse is preparing to administer a formula feeding by nasogastric tube (NGT) to a 2-month-old. Which intervention should the nurse implement?

Correct Answer is C

Explanation

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Scenario:
A nurse is caring for a 26-year-old gravida 2 para 1 female client in the labor and delivery unit.

Exhibits
The client receiving epidural anesthesia would be at risk for developing
dropdown
due to
dropdown
.