Which is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?
Maternal blood pressure.
Level of pain sensation.
Station of presenting part.
Variability of fetal heart rate.
The Correct Answer is A
Choice A rationale
Maternal blood pressure is crucial to monitor post-epidural anesthesia, as hypotension is a common side effect. Prompt detection and management of low blood pressure are vital to ensuring maternal and fetal well-being, making this the most important assessment.
Choice B rationale
Monitoring pain sensation helps determine the effectiveness of the epidural and the level of anesthesia. However, it is secondary to monitoring for hypotension, which can have more immediate and severe consequences.
Choice C rationale
The station of the presenting part is important for labor progression assessment but not as critical as monitoring for hypotension, which can significantly impact both the mother and fetus.
Choice D rationale
Fetal heart rate variability is vital, but immediate maternal hypotension management takes precedence, as it directly affects fetal oxygenation. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Checking serum human chorionic gonadotropin (hCG) levels is the appropriate action. hCG levels can help determine the viability of the pregnancy. Decreasing hCG levels may indicate a non-viable pregnancy, while increasing levels suggest a viable pregnancy.
Choice B rationale
Verifying the date of the last menstrual cycle is important but not the priority action in this scenario. While it can provide information on gestational age, it does not directly address the concern of vaginal bleeding.
Choice C rationale
Inquiring about the last occurrence of intercourse is not directly related to assessing the cause of vaginal bleeding. It may provide additional history but does not address the immediate concern.
Choice D rationale
Repeating a urine pregnancy test is not necessary in this context. The client is already known to be pregnant, and a urine test will not provide additional information regarding the cause of the bleeding.
Correct Answer is A
Explanation
Choice A rationale
Giving zidovudine 6 to 12 hours after birth is crucial as it helps prevent mother-to-child transmission of HIV. Early administration of antiretroviral medication reduces the risk of the newborn acquiring HIV significantly.
Choice B rationale
Administering antibiotics for 7 to 10 days is not standard practice for newborns of HIV-positive mothers unless there is an indication of infection. The primary intervention is antiretroviral therapy.
Choice C rationale
Delaying the initial bath for 1 to 2 days is not standard practice for preventing HIV transmission. It is important to bathe the newborn shortly after birth to remove any potential HIV-containing fluids.
Choice D rationale
Encouraging breastfeeding every 2 to 3 hours is not advised for HIV-positive mothers as HIV can be transmitted through breast milk. Alternatives such as formula feeding are recommended to prevent transmission. .
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