The nurse is caring for a client.
Which of the following findings would the nurse report to the anesthesia provider?
Pulse 88 bpm.
Pain of 1 on a 0 to 10 scale.
Blood pressure 88/52 mmHg.
Dizziness.
The Correct Answer is C
Choice A rationale
A pulse of 88 bpm is within the normal range for an adult and does not indicate any immediate concern that needs to be reported to the anesthesia provider.
Choice B rationale
A pain level of 1 on a 0 to 10 scale indicates that the epidural is effectively managing the client’s pain. This is a positive outcome and does not require reporting.
Choice C rationale
Blood pressure of 88/52 mmHg indicates hypotension, which is a common and potentially serious side effect of epidural anesthesia. Hypotension can lead to decreased placental perfusion and fetal distress, so it requires immediate attention and reporting to the anesthesia provider.
Choice D rationale
Dizziness can be a side effect of epidural anesthesia, but it is not as critical as hypotension. It should be monitored, but it does not require immediate reporting unless it is severe or accompanied by other symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Breech presentation means the fetus’s buttocks or feet are positioned to be delivered first. Fetal heart tones are often heard above the umbilicus in this position.
Choice B rationale
Transverse lie means the fetus is lying horizontally in the uterus. Fetal heart tones would typically be heard at the sides of the abdomen.
Choice C rationale
Cephalic presentation means the fetus’s head is positioned to be delivered first. Fetal heart tones are usually heard below the umbilicus in this position.
Choice D rationale
Oblique lie means the fetus is positioned diagonally in the uterus. Fetal heart tones can be variable depending on the exact position.
Correct Answer is B
Explanation
Choice A rationale
Variable decelerations are not related to the use of narcotic analgesics. Narcotic analgesics can cause other fetal heart rate changes, such as decreased variability, but they do not cause variable decelerations.
Choice B rationale
Variable decelerations are due to umbilical cord compression. This is the correct interpretation. Umbilical cord compression can lead to transient decreases in fetal blood flow and oxygenation, resulting in variable decelerations on the fetal monitor tracing.
Choice C rationale
Variable decelerations are not caused by maternal hypotension. Maternal hypotension can lead to late decelerations due to uteroplacental insufficiency, but it does not cause variable decelerations.
Choice D rationale
Variable decelerations are not indicative of fetal hypoxia. While severe and persistent variable decelerations can lead to fetal hypoxia, the primary cause of variable decelerations is umbilical cord compression.
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