The nurse is monitoring a client in active labor who has an epidural in place. Which of the following findings should be reported to the anesthesiologist immediately? (Select All that Apply.)

Slurred speech

Respiratory depression

Decreased sensation in the lower extremities

Sustained fetal heart rate of 150 bpm

Blood pressure 108/62

Answer and Explanation

Correct Answer : A,B

A. Slurred speech – Slurred speech may indicate systemic absorption of the epidural medication, leading to toxicity or excessive central nervous system depression, which requires immediate intervention.

B. Respiratory depression – A serious complication of epidural anesthesia is respiratory depression, which may result from excessive medication spread, affecting respiratory function. Immediate intervention is required.

C. Decreased sensation in the lower extremities – This is an expected effect of an epidural and does not necessarily require immediate reporting unless it extends beyond expected levels.

D. Sustained fetal heart rate of 150 bpm – This fetal heart rate is within the normal range (110-160 bpm) and does not indicate distress.

E. Blood pressure 108/62 – While hypotension can be a side effect of epidural anesthesia, this blood pressure is within an acceptable range for many clients and does not require immediate intervention unless the client is symptomatic.

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Correct Answer is D

Explanation

A. "Placenta previa usually results in a higher risk of maternal hypertension, while abruptio placentae is commonly associated with a low-risk pregnancy.
This is incorrect because abruptio placentae, not placenta previa, is associated with maternal hypertension (e.g., preeclampsia, chronic hypertension). Placenta previa is not related to blood pressure issues.

B. "Placenta previa is characterized by sudden onset of severe abdominal pain and uterine tenderness, while abruptio placentae is associated with painless bleeding."
This is incorrect because placenta previa presents with painless, bright red vaginal bleeding, while abruptio placentae causes sudden, severe abdominal pain, uterine tenderness, and possibly dark red bleeding.

C. "Placenta previa typically presents with severe pain and contractions, whereas abruptio placentae involves painless bleeding without contractions."
This is incorrect because placenta previa does not cause pain or contractions. In contrast, abruptio placentae often presents with painful contractions and uterine hypertonicity.

D. "Placenta previa involves the placenta partially or completely covering the cervix, whereas abruptio placentae involves the premature separation of the placenta from the uterine wall."
Placenta previa occurs when the placenta covers the cervix (partial or complete), leading to bleeding. Abruptio placentae occurs when the placenta prematurely separates from the uterine wall, which can lead to hemorrhage and fetal distress.

A. "We will monitor your blood pressure to see if it decreases." B. "We will check for a reduction in swelling and fluid retention." C. "We will assess for a decrease in seizure activity and improved reflexes." D. "You should feel less pain and have fewer headaches."

Correct Answer is C

Explanation

A. "We will monitor your blood pressure to see if it decreases."
While magnesium sulfate may have a mild antihypertensive effect, it is not primarily given to lower blood pressure; antihypertensives are used for that purpose.

B. "We will check for a reduction in swelling and fluid retention."
Edema in preeclampsia is due to capillary leakage and kidney dysfunction, not directly affected by magnesium sulfate.

C. "We will assess for a decrease in seizure activity and improved reflexes."
Magnesium sulfate is used primarily as a seizure prophylaxis in preeclampsia by stabilizing the central nervous system and reducing hyperreflexia and clonus, which are signs of worsening preeclampsia.

D. "You should feel less pain and have fewer headaches."
While magnesium sulfate can improve symptoms, it is not an analgesic and does not directly relieve pain.

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The nurse is monitoring a client in active labor who has an epidural in place. Which of the following findings should be reported to the anesthesiologist immediately? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the differences between placenta previa and abruptio placentae with a group of nursing students. Which of the following statements accurately differentiates placenta previa from abruptio placentae?

Correct Answer is D

Explanation

A nurse is monitoring a client who is receiving magnesium sulfate for severe preeclampsia. The client asks, "How will I know if the medication is working?" Which response by the nurse is most appropriate?

Correct Answer is C

Explanation

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