The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia is:
Limited perception of bladder fullness.
Severe afterbirth headache.
Hypotension.
Increased respiratory rate.
The Correct Answer is C
Choice A rationale
Limited perception of bladder fullness can occur with epidural anesthesia, but it is not the most common or harmful complication. Patients should be monitored for urinary retention.
Choice B rationale
Severe afterbirth headache, or post-dural puncture headache, can result from epidural complications, but it is less common than hypotension.
Choice C rationale
Hypotension is the most common and potentially harmful complication of epidural anesthesia. It occurs due to sympathetic nerve blockade, leading to vasodilation and decreased cardiac output. Normal blood pressure ranges: systolic 90-120 mmHg, diastolic 60-80 mmHg.
Choice D rationale
Increased respiratory rate is not a common complication of epidural anesthesia. It is more likely related to anxiety or other factors and should be monitored accordingly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Notifying the provider is important but does not address the immediate need to assess the patient's progress and readiness for delivery. A direct intervention is required to determine the next steps.
Choice B rationale
Performing a sterile vaginal exam allows the nurse to assess cervical dilation and effacement, fetal station, and presentation, which are crucial to determine if the patient is ready to push and proceed with delivery.
Choice C rationale
Supportive words and care are essential for patient comfort, but they do not provide the necessary assessment to determine the patient's progress in labor or readiness for pushing.
Choice D rationale
Monitoring the fetal heart rate tracing is important for assessing fetal well-being but does not specifically address the patient's readiness to push or her labor progress.
Correct Answer is B
Explanation
Choice A rationale
Occasional accelerations in fetal heart rate are generally reassuring, indicating fetal well-being and a positive response to movement or contractions.
Choice B rationale
Minimal or absent baseline variability is concerning because it can signal fetal hypoxia or central nervous system depression, indicating potential compromise in fetal oxygenation and well-being.
Choice C rationale
Early decelerations typically coincide with contractions and are often benign, resulting from fetal head compression that momentarily decreases heart rate but does not indicate distress.
Choice D rationale
A fetal heart baseline of 160 beats per minute is within the normal range (110-160 bpm), signifying an adequate fetal heart rate and not indicating immediate concern for the nurse.
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