The nurse is caring for a client who is 40-weeks gestation in active labor and has received epidural anesthesia.
What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia?
Station of presenting part.
Maternal blood pressure.
Variability of fetal heart rate.
Level of pain sensation.
The Correct Answer is B
Choice A rationale
While assessing the station of the presenting part is important during labor, it is not the most crucial assessment following the administration of epidural anesthesia.
Choice B rationale
Monitoring maternal blood pressure is the most important assessment following the administration of epidural anesthesia. Epidural anesthesia can cause a drop in blood pressure, which can lead to complications for both the mother and the baby.
Choice C rationale
Although assessing the variability of the fetal heart rate is important during labor, it is not the most crucial assessment following the administration of epidural anesthesia.
Choice D rationale
While assessing the level of pain sensation is important to evaluate the effectiveness of the epidural anesthesia, it is not the most crucial assessment following its administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Seizure activity typically presents with symptoms such as convulsions, loss of consciousness, or abnormal behavior, which are not described in the scenario.
Choice B rationale
Arrhythmia, or an abnormal heart rhythm, could potentially cause a sudden drop in oxygen saturation and cyanosis. It could also lead to a rapid response team being called.
Choice C rationale
Increased oxygen demand could potentially lead to low oxygen saturation. However, it would not typically cause cyanosis or require the rapid response team to be called unless it was associated with another condition such as heart or lung disease.
Choice D rationale
Acidosis, or a high level of acid in the body, could potentially cause low oxygen saturation. However, it would not typically cause cyanosis or require the rapid response team to be called unless it was severe or associated with another condition.
Correct Answer is B
Explanation
Choice A rationale
If the child is sleeping now and is difficult to wake, this could be a sign of worsening respiratory status. Children with respiratory distress often have difficulty sleeping due to discomfort and difficulty breathing. If the child is now sleeping and difficult to wake, this could indicate a decrease in oxygen levels, leading to lethargy and decreased responsiveness. This would require immediate attention.
Choice B rationale
The vital signs provided indicate a potentially serious situation. A heart rate of 130 beats/minute is high for a 3-year-old child, indicating that the heart is working harder to pump blood. A respiratory rate of 15 breaths/minute is on the lower end of normal for a 3-year-old, which could indicate that the child is not getting enough oxygen. An oxygen saturation of 66% on a 5L face mask is dangerously low, indicating severe hypoxia. A temperature of 102.8° F(39.3° C) axillary indicates a fever, which could be a sign of infection. A blood pressure of 92/48 mm Hg is within normal range for a 3-year-old.
Choice C rationale
If the child is active and playing with toys, this could indicate that his respiratory status is not worsening. Children who are experiencing respiratory distress often have difficulty engaging in normal activities due to discomfort and shortness of breath. If the child is able to play normally, this could indicate that he is getting enough oxygen and his condition is stable.
Choice D rationale
If the child’s breathing has returned to normal, this could indicate that his respiratory status is improving. However, it’s important to continue monitoring the child closely, as respiratory conditions can change rapidly, especially in young children.
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