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. .
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
This choice suggests assessing if the child can administer the insulin. While it's important for children with diabetes to learn self-care skills, a 10-year-old may not yet be ready to take on the responsibility of injecting insulin regularly. The child might still rely on parental or caregiver support for this task. Moreover, it does not address the immediate issue of the mother's fear of needles.
Choice B rationale
This choice focuses on assessing the mother's parenting skills. It is not directly related to solving the issue of insulin administration. The mother's fear of needles does not necessarily reflect her overall parenting skills. Assessing parenting skills would not provide a practical solution to the child's need for insulin administration.
Choice C rationale
Encouraging the mother to handle the needles could help overcome her fear, but it might not be effective in the short term. The mother might need time and professional help to deal with her fear of needles. This choice does not provide an immediate solution for the child's need for insulin injections.
Choice D rationale
Asking if the father can help with the injections is a practical and immediate solution. If the father is available and comfortable with handling needles, he can take on the responsibility of administering insulin to the child. This ensures that the child's medical needs are met while giving the mother time to overcome her fear of needles.
Correct Answer is B
Explanation
Choice A rationale
Oxytocin is not involved in returning the uterus to its prepregnancy size. Instead, it helps in uterine contractions, which facilitate the expulsion of the placenta and reduce postpartum bleeding. The process of uterine involution, returning to prepregnancy size, is primarily managed by the natural decline of pregnancy hormones and autolysis of uterine tissue.
Choice B rationale
Oxytocin stimulates uterine contractions, which is its primary function during labor and after delivery. These contractions help deliver the baby during labor and facilitate the expulsion of the placenta. After delivery, oxytocin continues to induce contractions to minimize postpartum hemorrhage and aid uterine involution.
Choice C rationale
Oxytocin can activate the let-down reflex for breastfeeding, but it is not the primary expected outcome when administered IV after delivery. The main goal post-delivery is to manage uterine contractions to prevent hemorrhage and assist in expelling the placenta.
Choice D rationale
While oxytocin assists in expelling the placenta by stimulating contractions, this is not its primary use post-delivery. The placenta typically detaches and is delivered shortly after birth. Oxytocin's main role after delivery is to continue stimulating contractions to reduce bleeding and help the uterus return to a non-pregnant state.
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