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.

Answer and Explanation

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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Correct Answer is D

Explanation

Choice A rationale

Typing and crossmatching for a possible transfusion is not the immediate priority for a child with hemophilia who has a swollen knee. While a transfusion might be necessary if there is significant bleeding, initial management should focus on controlling the bleeding and minimizing joint damage.

Choice B rationale

Initiating an IV site and beginning infusing normal saline is not the first action to take in this scenario. While IV access might be needed later, immediate measures should focus on controlling bleeding and reducing swelling to prevent further damage to the knee joint.

Choice C rationale

Monitoring the child's vital signs frequently is important, but it is not the first action to take. The priority is to control the bleeding and reduce the swelling, which are the immediate concerns in this situation.

Choice D rationale

Applying an ice pack and compression dressing to the knee is the first action to take. This helps to control bleeding, reduce swelling, and minimize joint damage. This is a crucial step in managing hemophilia-related injuries and should be done immediately upon recognizing a swollen joint.

A. Have the antibiotic trough level drawn within 3 days. B. Continue strict monitoring of daily wet diapers for 1 week. C. Administer antipyretic medication on a continuous basis. D. Monitor the infant for response to auditory stimuli.

Correct Answer is D

Explanation

Choice A rationale

In bacterial meningitis, monitoring antibiotic levels is critical during treatment to ensure therapeutic effectiveness and avoid toxicity. However, it is not necessary to check antibiotic levels after completing the course. The body clears the antibiotics within a few days, and monitoring is more relevant during therapy.

Choice B rationale

While monitoring wet diapers is important during illness, it's not necessary to continue strict monitoring post-treatment. Wet diapers track hydration and renal function, which should normalize after successful treatment.

Choice C rationale

Continuous use of antipyretics is unnecessary post-treatment. Fever management is more critical during active infection. Post-treatment, fevers should subside, making continuous medication redundant and possibly harmful.

Choice D rationale

Auditory monitoring is crucial after meningitis due to the risk of hearing loss, a common complication. Early detection of auditory issues allows for timely intervention and support for the child’s development.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A child with hemophilia arrives at the clinic with a swollen knee after falling off a bicycle. Which action should the nurse implement first?

Correct Answer is D

Explanation

Upon completion of a 14-day antibiotic treatment for bacterial meningitis in an infant, the nurse prepares the family for discharge. Which information should the nurse include?

Correct Answer is D

Explanation

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