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 A
Explanation
Choice A rationale
Monitoring the capillary refill of the toes is crucial when a child has a long-leg cast applied. This is because it helps assess the adequacy of circulation to the foot, which can be compromised by the cast. If the capillary refill is delayed (more than 2 seconds), it could indicate poor blood flow to the area, which could lead to serious complications such as tissue necrosis.
Choice B rationale
Comparing the temperature of both legs can provide information about circulation and inflammation. However, it is not the most important action in this case. While a significant difference in temperature could indicate a problem, it is not as direct an indicator of circulatory status as capillary refill.
Choice C rationale
Observing for spontaneous movement can provide information about nerve function. If the child is not moving the toes, it could indicate nerve damage. However, lack of movement could also be due to discomfort from the cast and is not as direct an indicator of circulatory status as capillary refill.
Choice D rationale
Checking the femoral pulses can provide information about circulation to the leg. However, the femoral pulse is proximal to the cast and may not accurately reflect circulation to the foot. Therefore, it is not the most important action in this case.
Correct Answer is ["0.72"]
Explanation
Step 1 is to calculate the total amount of oxytocin in the IV bag. This is done by multiplying the total volume of the bag by the concentration of oxytocin. In this case, the bag contains 5 units of oxytocin in 500 mL, so the concentration is 5 units ÷ 500 mL = 0.01 units/mL.
Step 2 is to convert the prescribed dose from milliunits/min to units/hour. There are 1000 milliunits in a unit and 60 minutes in an hour, so 12 milliunits/min = 12 ÷ 1000 units/min = 0.012 units/min. Then, 0.012 units/min × 60 min/hour = 0.72 units/hour.
Step 3 is to calculate the infusion rate in mL/hour. This is done by dividing the prescribed dose in units/hour by the concentration of oxytocin in units/mL. So, 0.72 units/hour ÷ 0.01 units/mL = 72 mL/hour. Therefore, the nurse should set the infusion pump to 72 mL/hour.
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